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Wiki History of code

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jharrell

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How would you code "history of fracture "if they didn't state weather it is pathologic, stress, or traumatic? I want to say that there is not enough info to code it, but was having seconds thoughts. thanks

Jessica Harrell, CPC
 
Personally, I don't code it unless I have that information provided by the MD. Many times,pathologic can be a result of OA which is a far cry from a fall and sustaining a traumatic fx.

Just my two cents~
 
History of fracture

Hi Jessica,

I'm with you - I would totally agree that there is insufficient documentation as to whether this was pathologic, traumatic or stress in nature.

Some scenarios do have a very benign and basic code that can be applied but not in this case.

This is one that needs to go back to the source for clarification.

Have a good day,

Joyce ;)
 
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