person who has a fracture was diagnosed with S32.2XXA and fell at home. This was the only code reported. She was seen in the ER and then came to see her physician. How would this be coded? Would this be initial encounter or subsequent? Could this be a primary code along with the place of injury?
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CodingKing
True Blue
Active treatment phase would be initial. it doesn't change to subsequent based on it being a different physician.
mitchellde
True Blue
If the fracture were treated in the ER and the patient was sent to your provider for follow up then the visit in your office is subsequent. If the ER was unable to treat the fracture and sent the patient to your provider for fracture treatment then the visit in your office is initial. The place of injury is coded only on the initial encounter. The code for the fall 7th characters follows the same rule as the fracture code.
CodingKing
True Blue
Sorry I should have realized S was external cause not the fracture. Although is there anything I the guidelines that state you should only use external cause for initial encounter. All I can find is the comment about it not being mandatory but encouraging provider to use them
mitchellde
True Blue
The S code is the fracture code. There are 4 types of external causes. The cause of the injury, the place of the injury the activity of the patient and status of the patient. The cause of the injury are the ones with the 7th characters. The place and activity are only applied at the initial encounter. This is stated in the guidelines. External cause codes start with V, W, X, or Y.