Wiki Initial VS Subsequent visit confuse

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Prakash Ignatious

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Hi all,

Please advise if any time frame for Initial and Subsequent Visit for Fracture encounter like Reduction,fixation .

Below is the example chart to couldn't assign correct ICD 10. DOS is in exam date. I need your valuable suggestion.

RIGHT RADIUS SHAF
CLOSED REDUCTION RIGHT RADIUS ULNA, DONE
PROCEDURE ACKNOWLEDGE DATE: 10/15/2015 08:30 AM
INTRAOPERATIVE DIGITAL RADIOGRAPHY RIGHT WRIST 4 VIEWS 10/15/2015
0817 HOURS
COMPARISON: 10/10/2015 1809 HOURS
INDICATION: REDUCTION OF DISTAL RADIAL ULNAR FRACTURE
FINDINGS: THE 2 FINAL VIEWS DEMONSTRATE NEAR-ANATOMIC ALIGNMENT IN
PLASTER. DETAILS OF THE PROCEDURE TO BE FOUND IN THE OPERATIVE
REPORT.
IMPRESSION: NEAR-COMPLETE REDUCTION IN PLASTER
 
Prakash Ignatious said:
Hi all,

Please advise if any time frame for Initial and Subsequent Visit for Fracture encounter like Reduction,fixation .

Below is the example chart to couldn't assign correct ICD 10. DOS is in exam date. I need your valuable suggestion.

RIGHT RADIUS SHAF
CLOSED REDUCTION RIGHT RADIUS ULNA, DONE
PROCEDURE ACKNOWLEDGE DATE: 10/15/2015 08:30 AM
INTRAOPERATIVE DIGITAL RADIOGRAPHY RIGHT WRIST 4 VIEWS 10/15/2015
0817 HOURS
COMPARISON: 10/10/2015 1809 HOURS
INDICATION: REDUCTION OF DISTAL RADIAL ULNAR FRACTURE
FINDINGS: THE 2 FINAL VIEWS DEMONSTRATE NEAR-ANATOMIC ALIGNMENT IN
PLASTER. DETAILS OF THE PROCEDURE TO BE FOUND IN THE OPERATIVE
REPORT.
IMPRESSION: NEAR-COMPLETE REDUCTION IN PLASTER
Click to expand...
I cannot tell from this which date you are trying to code. If the 10/10 date was the initial treatment of the fracture then that would be an A. The 10/15 encounter appears to be a follow up so it would subsequent.
However I am not sure the 10/10 encounter is the initial treatment or another follow up the information is not clear.
 
My apologize , i didn't mention the DOS . According to report 10/15 is DOS and it is follow up treatment but the documentation does't has fixation or relevant findings instead of it has intra operative studies.

ICD 10 CM guideline, explains 7th digit as A - for initial encounter and Active treatment
D- subsequent encounter for fixation/removal of internal and external, follow up visit.

Is there any time frame for this Two encounters? An above report, patient encounter came after 5 days of Active treatment .If so how can i assign as 7th digit D?
Please advise it.
 
Prakash Ignatious said:
My apologize , i didn't mention the DOS . According to report 10/15 is DOS and it is follow up treatment but the documentation does't has fixation or relevant findings instead of it has intra operative studies.

ICD 10 CM guideline, explains 7th digit as A - for initial encounter and Active treatment
D- subsequent encounter for fixation/removal of internal and external, follow up visit.

Is there any time frame for this Two encounters? An above report, patient encounter came after 5 days of Active treatment .If so how can i assign as 7th digit D?
Please advise it.
Click to expand...
I am not reading this as any procedure being performed just a review of the X-ray. Do you have a procedure note for the 10/15 date? If so was it due to a malunion or nonunion of the previous reduction?
The 10/10 references an op report so I as sim that was the date the reduction was performed so it is the initial active treatment. 5 days later if additional treatment is needed then the question is why. If this was a two stage procedure then that would have been mentioned on the initial report. However if a second procedure is necessary due to a mal union or non union then that is subsequent. There is really not enough information in what you have provided to show continued active treatment.
 
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