Wiki Billing for ruling out the fracture of the spine

[kinga76pl]

What code should be used while ruling out the fracture of Vertebral body of L4. The patient was seen in the office, the x-ray was taken and showed chronic appearing fragmentation of the anterosuperior aspect of the L4 vertebral body. Initially we used CPT 99214 and 22315. Patient was sent for CT scan but never followed up. Patient did not receive a brace or cast. Patient received a referral to a spine specialist.

 

[thomas7331]

This is a basic of coding: for outpatient/office encounters, if you do not have a confirmed diagnosis, you code the symptoms.

 

[amyjph]

You wouldn't code closed treatment of the fracture. The code requires casting/bracing and manipulation or traction to be done. It would just be the office visit (going by the brief info here). We would have to see specific documentation to advise anything else. What did the assessment say the diagnosis was? That's what you code for the diagnosis. Like Thomas said, if there is no definitive, you go to symptoms.