Documentation Guidelines for Fracture Care

urbach34@yahoo.com

Networker
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Is there a bullet point list somewhere of documentation guidelines for fracture care? My office is trying to help compile a list for our physicians that outline what they need to document in their office note in order to warrant billing fracture care.
 

esimonsen

Contributor
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San Francisco
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Anyone know about this?

I am having the same problem too. We got a denial for not enough documentation for reduction, but I cannot find anything to show them as far as what I need them to be documenting. Below I removed all the HPI and Exam, just showing the MDM and treatment which I admit is sparse, and I don't know how to advise them to bulk it up.

STUDIES:
XR of the left ankle demonstrate lateral displaced, translated distal fibula
fracture. No obvious medial malleolus fracture.

IMPRESSION:
Left ankle bi-malleolar ankle fracture equivalent.

PLAN:
1. Fracture was reduced by myself. Post reduction films demonstrate excellent
reduction.
2. Left ankle was splinted with a AO splint by myself in a well padded and
molded splint.
3. NWB LLE with crutches.
4. Plan for outpatient follow up with my office at the end of this week for likely surgery next week.
 

hblakeman

Networker
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I can't find a specific example, but our physicians will document the reduction as a procedure. They state how/where they manipulated the fracture (such as where they pushed or pulled out to length) if they used traction, etc.
 

Orthocoderpgu

True Blue
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Salt Lake City, UT
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Needs to document that fracture care is being initiated

I have had denials too. I have the physicians state that they are initiating fracture care, usually done in the assessment.
 

daedolos

Expert
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461
Location
Long Beach
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I can't find a specific example, but our physicians will document the reduction as a procedure. They state how/where they manipulated the fracture (such as where they pushed or pulled out to length) if they used traction, etc.

I agree. You will need a procedure note not as detailed as an op report but showing medical necessity and actions taken as well as pre and post operative notes. It probably wouldn't entail more than four sentences.

Peace
@_*
Just saying
 
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