Alamogal
Guest
Q1: What type of documentation would you expect to see in a patient's medical record for fracture treatment without manipulation?
Q2: Does the below documentation support billing fx care (e.g., 25600-closed tx of distal radial fx w/out manipulation) or an E/M service?
Hx: A left distal radius injury when fell on outstretched hand and was seen at outside facility and placed in a removable splint. Comes in today for f/up evaluation.
Physical exam: skin intact on his left distal radius, does have some swelling, minimal tenderness to palpation, brisk capillary refill to fingers, can flex fingers on left hand, has no gross deformity.
X-ray reviewed: distal radial metaphyseal fracture with apex dorsal angulation with approx 10 degree angulation.
Assessment: Lest disbal radial metaphyseal fracture.
Plan: Acceptable alignment, so will place him in a short arrm cast on the left and keep out of athletics for 5-6 weeks.
Note:
*Patient is seen in an outpatient hospital location where the physician does not work for the hospital and will be billing his services through a physicans group practice.
*Cast is placed by the cast tech who works for the hospital, not the physician.
References are appreciated.
Thanks.
Q2: Does the below documentation support billing fx care (e.g., 25600-closed tx of distal radial fx w/out manipulation) or an E/M service?
Hx: A left distal radius injury when fell on outstretched hand and was seen at outside facility and placed in a removable splint. Comes in today for f/up evaluation.
Physical exam: skin intact on his left distal radius, does have some swelling, minimal tenderness to palpation, brisk capillary refill to fingers, can flex fingers on left hand, has no gross deformity.
X-ray reviewed: distal radial metaphyseal fracture with apex dorsal angulation with approx 10 degree angulation.
Assessment: Lest disbal radial metaphyseal fracture.
Plan: Acceptable alignment, so will place him in a short arrm cast on the left and keep out of athletics for 5-6 weeks.
Note:
*Patient is seen in an outpatient hospital location where the physician does not work for the hospital and will be billing his services through a physicans group practice.
*Cast is placed by the cast tech who works for the hospital, not the physician.
References are appreciated.
Thanks.