TMcFadden
New
Have a doctor who saw patient in ED for Oral Lacerations and Orbit fracture. In the consult he states he will be operating on the oral lacerations but will manage the orbit fracture non operatively.. Coded for the consultation. Listing fractures in diagnosis.
Dr. then does operation from ED for the Oral lacerations but also lists 21400 for Non operative management. There is no mention on the Orbit fracture in the op note. Dr. states cannot dictate something he is only managing. He wants 21400 billed because he is managing the orbital fracture.
I am extremely hesitant because there is no notation of the orbit fracture in the op note and I have been told that 21400 is an actual procedure. Dr. says no that because it has no manipulation it is not a procedure. Can someone please help clear this up.
His feeling is that he should be compensated for managing the fracture. My feeling is there should be some notation and I am not sure that 21400 would be the right code.
TIA for any help that can be given!!!
Dr. then does operation from ED for the Oral lacerations but also lists 21400 for Non operative management. There is no mention on the Orbit fracture in the op note. Dr. states cannot dictate something he is only managing. He wants 21400 billed because he is managing the orbital fracture.
I am extremely hesitant because there is no notation of the orbit fracture in the op note and I have been told that 21400 is an actual procedure. Dr. says no that because it has no manipulation it is not a procedure. Can someone please help clear this up.
His feeling is that he should be compensated for managing the fracture. My feeling is there should be some notation and I am not sure that 21400 would be the right code.
TIA for any help that can be given!!!