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Wiki Coding a Fracture

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Lulu20

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This is regarding outpatient services- Can a MD code for a fracture without doing an X-ray first? I am not finding anything online saying that a fracture has to be proven by x-ray before it can be coded. Any help on this would be greatly appreciated.
 
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I do not typically code orthopedics. That being said, unless there is evidence contradicting the physician's assessment of a diagnosis (in which case I would query the physician), I assume the physician has more medical knowledge than I do, and do not question his/her assessment.
Here would be 1 example where it would clearly be appropriate to code fracture without (or before) xray - the bone is protruding from the skin.
I do educate my clinicians that they should code based on the current evidence, and never rule out diagnoses (in the office setting). I work in gynecologic oncology, and there are certainly situations where we know it's cancer; there is a large growing mass, ascites, a strong family history of ovarian cancer, and a very elevated tumor marker test, but until there is pathology, the physician does not code as cancer. We code as just that - mass, ascites, family hx & elevated lab until surgery is done.
 
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