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christy0708

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If a pt is seen as new pt and has a fracture but in order to determine what needs to be done a ct scan has to be taken. After the ct scan is obtained patient follows up with surgeon and they decide on doing surgery...can i on the first visit, charge for closed fracture care in addition for billing for the surgery that happens about a week later. I am unsure if i agree with this. I think that the first visit should have just been em service and on the second visit if surgeon decided against fx care then closed fracture care service should have been billed, not both of them. However, i do lack experience on this matter. Any input would be appreciated
 
Maybe...BUT..on the first visit..what EXACTLY was done? Was the fracture confirmed? was the patient treated for the fracture? how long before the CT was completed and definitive management was planned?
 
christy0708 said:
The fracture was confirmed..patient had CT and followed up in a week.surgeon decided for surgery which was done in the same week
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You can capture the closed treatment of the fracture on the first visit IF THE DOCUMENTATION SUPPORTS TREATMENT OF THE FRACTURE (ie casting, splinting, care/restrictions given to patient)

When the doc takes the patient to the OR for the ORIF, you will need to use the 58 modifier.
 
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