How to code injuries

tristate

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I bill for a radiologist who reads x-rays done at a hospital. Many times (Emergency Dept mostly) the only diagnosis I get is something like "hand caught in door" or "patient fell". According to a 2006 Coding Clinic publication they advise not to assume injury when the diagnosis is "trauma" because "trauma" is not always indicative of injury. Are there any radiology coders who can tell me how they handle these situations? Thanks!
 

cblack712

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When the terms are general and not direct for "injury" we have been told to code the V71.4 (observation following accident) is what our group has been directed to use. For some carriers that isn't a covered code and we will have to go and get the med reports from the ER stating that the patient "caught and in door and there is swelling / pain" 95% of the time the ER notes have what you need
 

asmonger

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2ndary E-codes

I would agree with the V-code primary if there isn't enough documentation or you are unable to ask the provider to elaborate. I would also follow with a secondary E-code that might be able to better describe what happened i.e. accidental fall.
 
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mitchellde

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When the terms are general and not direct for "injury" we have been told to code the V71.4 (observation following accident) is what our group has been directed to use. For some carriers that isn't a covered code and we will have to go and get the med reports from the ER stating that the patient "caught and in door and there is swelling / pain" 95% of the time the ER notes have what you need
V71.4, all V71 codes, are for use when the study is performed and nothing is found, so if there had been an incident and there is no finding of injury on xray then you would use the V71.4 followed by the appropriate E code, but you would not use the V71.4 if there is a description of an injury or there is an injury found on film. it is not an observation following accident, you must read the V71 main heading and attach that descriptor to all V71 codes, they are for conditions suspected but not found.
 

cblack712

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V71.4, all V71 codes, are for use when the study is performed and nothing is found, so if there had been an incident and there is no finding of injury on xray then you would use the V71.4 followed by the appropriate E code, but you would not use the V71.4 if there is a description of an injury or there is an injury found on film. it is not an observation following accident, you must read the V71 main heading and attach that descriptor to all V71 codes, they are for conditions suspected but not found.
Thank you for elaborating on that Deborah, I always assume that everyone would know to code to the highest level.... (ie - hand caught in door as the reason and a fracture is discovered, you would ofcourse code the fracture) as opposed to the V code.
 
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