Wiki Fracture Wrist Coding

[cwilson3333]

Would like to have opinion on the coding of this encounter for wrist fracture:

CC: Fracture wrist
HPI: The patient is an 11-year old left hand dominant male who injured his left wrist
on 8-15-13. He fell from off his skateboard.
No prior orthopaedic problems. He went to Urgent Care
PE: WDWN male. Left Wrist: Moderate Swelling. He is tender over the distal radius
and ulna. Elbow nontender. NVI; Skin intact. No obvious deformity.
XRAYS: Viewed on computer show a fracture of the distal radius and probably distal
ulna.
ASSESSMENT: Fracture of distal radius and ulna
PLAN: Short arm cast. F/u in a week for an Xray check. The cast will be in place for
4-6 weeks.

DR/transcriber
Date of Injury: 8-15-2013
Xrays performed: Urgent Care


The remaining EHR I won't list but is documented for Current medication, allergies, PSFH, and 3 vitals were taken.

99203-25
29075
ICD: 813.44
E885.2

[I bill itemized visits vs fracture treatment]

 

[adricpc]

Without more E/M info, this may only be 99202.

You may be entitled to also bill the 'Q' code for materials, depending on where the E/M was rendered and if the casting materials belonged to your doctor.

 

[cwilson3333]

distal radius and ulna fx tx

Why not the billing of the application of the short arm cast also ? I would also bill Q4050 for the Gortex cast liner if it was used.

I do itemized billing vs global fracture coding.

Thanks
CW