Intra-articular fracture-# fragments not documented

[Carsil864]

My Orthopedic surgeon has documented that he performed an ORIF of an intra-articular distal radius fragment, 3 or more fragments (25609), however he did not indicate the number of fragments nor can I pull this information out of the op report. I have asked him to append his note but his response was "I will not be amending the OP note, you can code as you see fit". What do I do in this case? Do I code extra-articular (25607) or intra-articular, 2 fragments (25608) with a 52 modifier? Thank you.

 

[Orthocoderpgu]

If anywhere in the body of the op note he indicates that there is comminution, I would consider giving it to him. Or if you can see that he has fixated three bony fragments. Usually done with K-wire. I spoke to one of our docs about this situation. Even if the fracture is repaired with a plate, so you would not necessarily be able to see the individual fragments being reduced, there is a greater risk of failure and complications after the procedure.