Compression Fracture coding

coderwhtf

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Hello,
Does anyone know if AAPC have any updated information on Compression Fracture in the coding clinic or AHA information? I am trying to understand the guidelines surrounding the coding. Meaning if not stated as acute, the fracture is automatic assume pathology if the member has a disease of the bone (osteoporosis) without it being stated in the record and when there is no clarification on how the original fracture happen? For instance note below.
Mr. XYZ with hx of advanced stage III multiple myeloma, status post six courses of melphalan and prednisone with thalidomide in 12/07 stopped after secondary courses due to neuropathy. He has been stable and doing well ever since. He continues to see his rheumatologist and is on leflunomide. He has been doing well, good appetite, putting on weight. He finally got a prosthetic left leg and is now walking with a walker. Unable to get reclast due to insurance issues. Last bone density was 7/09. Since the last time, I saw him on 01/15/10 he did have a skeletal survey 01/20/10, which was stable with the known compression fracture again seen at the level of T4 vertebral body.

Assessed with: Compression Fracture, stable. Not wearing a brace anymore.

Question: Should this be the V- code for aftercare of initial fracture follow-up care because we do not know the original cause of fracture OR the pathology (compression) Fracture code because he has a known bone disease?

If you could direct me to a different source I would appreciate any help surrounding this issue.
 

cjacobs

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If PT has osteoporosis with a compression fracture, then I would code it for the compression fracture along with osteoporosis. If there is any doubt as to what is going on with PT, then I would make a phone call to the Referring Physician or Medical Records department to find out the information needed to code properly. Hope this help
 
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