Wiki Fracture Diagnosis

[Kris78]

Will someone please shed some light on fracture diagnosis coding?
Specifically pertaining to coding to the highest specificity when the provider is not too specific in their note.

Example:
Orthopedic consult in the hospital states that the patient has a left distal radius fracture and will require stabilization.
I'm left to coding s52.50xx. If I look at the radiology report and also his op note preoperative dx the following day they both state left distal radius intra-articular fx which would allow a more specified code.

**side note: if the provider documentation does not identify the location of an infarction I am allowed to use imaging reports to pinpoint location and use a more specific infarction code**

question here is:
Am I allowed to do the same for fractures? Can I refer to the radiology report or another note in the record that specifies the type of fracture? and if so where does it state that? I have looked and looked with no luck.

thanks in advance for your help!

 

[ealvarez113@hotmail.com]

This is where you would need to query the provider, for a more detailed diagnosis and have him amend his operative report. We never go by radiology report. Its always whats documented in operative report and/or pathology report. I hope this helps.