Wiki Help with fracture coding

bostonmom

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Hi everyone! I have a podiatrist that is trying to bill fracture care for a patient but the xray and bone scan are not showing any fractures.
X-ray Foot Left 2 Views
Narrative: Lateral calcaneal axial the left heel. Bone spur present on the inferior heel. No change from prior exam. No evidence of stress fracture. Assessment: Left foot with plantar calcaneal spur and no acute findings

Nm Bone Scan Three Phase
Exam:NM bone scan three phase Diagnosis:pain Calcaneal spur, left Chief complaint: Left calcaneal?bone pain History: Pt is a runner and has had chronic Left heel pain since summer 2018 Additional Tech Information: Administered dose: 25.5 mCi Tc-99m MDP PROCEDURE Three-phase bone scan Images were centered over the feet and ankles after radiotracer administration COMPARISON Left foot x-ray from January 14 FINDINGS There is not significant asymmetry on blood flow On the delayed images there is some intense activity along the left plantar calcaneal spur with perhaps very mild asymmetric activity in that region on the blood pool image There is also subtle asymmetric blood and intense delayed activity near the tarsometatarsal joint near the base of the third or fourth metatarsal at the left mid foot with similar but less impressive activity on the right side on delayed imaging There is otherwise some focal activity at the right mid foot Lisfranc articulation on delayed imaging IMPRESSION: Intense delayed activity at the left calcaneal spur region with only mild low-level blood pool activity. This may be sequelae of prior plantar fasciitis. Acute active plantar fasciitis or stress injury is less likely There is some mild blood pool and delayed activity at the left mid foot near the articulation of the cuboid or cuneiform with the base of the fourth and third metatarsal region. This could be arthritic or related to a stress injury There is also some delayed activity at the right foot midfoot and Lisfranc articulation If this patient has persistent or worsening symptoms and more detailed imaging is needed, MRI might be considered assuming no contraindication. -----------------------------------------------------------------------

I had advised the provider that we could not bill for fracture care because there was not a fracture or even a stress fracture, that likely is not allowed. The provider is arguing with me. Here is his response:
Patient has disabling pain on the plantar heel for 6 months that is consistent with fracture. She describes pain at rest which is consistent with bone pain and not plantar fasciitis. Radiologist stated:
Intense delayed activity at the left calcaneal spur region with only mild low-level blood pool activity. This may be sequelae of prior plantar fasciitis. Acute active plantar fasciitis or stress injury is less likely
So this is not a “prior plantar fasciitis”. She still has pain. This is not just plantar fasciitis with her complaint of pain when at rest. Patient does not have an infection in her heel. There is no evidence of tumor on the x-ray. Diagnosis of calcaneal stress fracture is most likely. She is being treated for a stress fracture in a cast boot. So this may be “ less likely ” to the radiologist but it is my opinion that fracture is the most likely diagnosis based on the patient's symptom patterns.
I think the code should stay

I cannot find any documentation to support that we cannot bill for less likely or most likely fractures that are in the drs opinions. Can anyone please help me?
 
less likely and most likely are terms of uncertainty. the guidelines do state that physician coders are not to code an uncertain diagnosis.
 
Even if it's not on the x-ray, the doctor is the doctor, and gets to decide if it's a fracture or not. If he says "it's a stress fracture," that's what you need to code. But he needs to commit to it being a fracture--not that it's the "most likely" answer.
 
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