Coding Fractures

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36
Location
Largo, Florida
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0
Hello everyone,

I am hoping for some input on coding fractures. I am trying to code a recent encounter and one of the diagnoses states left ankle fracture/ Dexa scan ordered. It does not state anything more specific. Looking in the chart, I can see that back in July, the patient called in stating he thinks he broke some bones in his ankle, but again, nothing specific about how it happened etc. Lastly, I reviewed the notes from the Orthopedic in July and it states that the patient was playing golf and felt a pain in his left ankle. he did not fall, just felt the pain after he hit the ball. I have always been somewhat confused because I have been told by some that a note stands alone so you can only code based on that note whereas others state to review the entire medical record. Please help! as it stands, what code would be best?
 

Orthocoderpgu

True Blue
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1,654
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Salt Lake City, UT
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9
I would just use unspecified ankle fracture diagnosis code. The DEXA is not for potentially viewing the fracture, but seeing if the patient has osteoporosis. You would have to have pretty severe osteoporosis to fracture your ankle during a golf swing. Notes do need to stand on their own and it would be better if you had more specific information. If you are allowed to query the physician for a more specific diagnosis I would do that, but otherwise your stuck with using an unspecified code.
 
Messages
36
Location
Largo, Florida
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0
I appreciate your quick response! I still need to clarify a few things if you don't mind...I came up with code S82.92XD (Unspecified fracture of left lower leg, subsequent encounter for closed fracture with routine healing ) because the documentation stated it was the left ankle. Guidelines state to use Subsequent for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase. Would you agree that this is the correct code choice since the Dexa is routine care after a fracture? Also, I could not find fracture unspecified in the code book, I searched online. How do you find it in the code book? When I search Fracture, it lists several types but not unspecified that I can see.
 
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