NikkiaBush
New
If a patient comes in due to an accident like a car accident or a fall and the report is negative what code do we use? I was instructed to code trauma to injury because of the see also note and use the study conducted to assign an injury location. Example 1 would be coded to unspecified injury of thorax S29.9XXA. Example 2 would be coded to unspecified injury of hip for the hip x-ray, unspecified injury of knee for the knee X-ray etc. I need an official guideline or article about this if anyone has anything I would greatly appreciate it.
Example 1-
Indication (reason for the exam on the order): trauma
XR chest 1 view
FINDINGS:
No evidence of pneumothorax.. The cardio mediastinal silhouette and pulmonary vasculature are within normal limits. There is no acute osseous abnormality.
IMPRESSION:
No evidence of pneumothorax. No fractures or musculoskeletal abnormalities.
Example 2 -
Indication/ordering DX: trauma, ATV accident
XR Ankle right 3 or more views,XR right knee 3 views, XR right hip 2 or 3 views, XR foot right 3 or more views
Findings: Right hip joint space is maintained. No pelvic or hip fractures, No knee joint effusion, Knee alignment is normal. Ankle mortise is symmetric. No displaces fracture.
Impression:
No acute fracture.
Example 1-
Indication (reason for the exam on the order): trauma
XR chest 1 view
FINDINGS:
No evidence of pneumothorax.. The cardio mediastinal silhouette and pulmonary vasculature are within normal limits. There is no acute osseous abnormality.
IMPRESSION:
No evidence of pneumothorax. No fractures or musculoskeletal abnormalities.
Example 2 -
Indication/ordering DX: trauma, ATV accident
XR Ankle right 3 or more views,XR right knee 3 views, XR right hip 2 or 3 views, XR foot right 3 or more views
Findings: Right hip joint space is maintained. No pelvic or hip fractures, No knee joint effusion, Knee alignment is normal. Ankle mortise is symmetric. No displaces fracture.
Impression:
No acute fracture.