Kyphoplasty diagnosis

AlwaysLearningCoder

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Is it allowable to assume that most all compression fractures are caused by osteoporosis and there for add the secondary diagnosis as such since the MD stated compression fracture in the dictation (if it has not been listed or mentioned in any of her notes)? also is it then acceptable to have the doctor write an addendum adding the diagnosis even if it had never been introduced before? May i have a response as to how fraudulant this is for my bosses..?
:) thank you
 
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733.10 Pathologic Fracture, cause unknown

It's never safe to assume anything when coding.
If it's not written down it didn't happen.

But, from your brief scenario you do say that "MD stated compression fracture" so you could use Dx code 733.10.

As education for the physician, you might want to photocopy the couple of pages from ICD-9 that deal w/ Kyphosis and let him/her know that being more specific in dictation would allow you to correctly code the scenario.

Remember that what you code becomes a part of a patient's record. You don't want to give them a disease they may not have.

F Tessa Bartels, CPC
 

LaSeille

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code for kyphoplasty

If the physician documented vertebral compression fracture, then code as 733.13 (specific to vertebrae). However, to just go ahead and "assume" that it is due to osteoporosis - NO, you cannot "assume" anything. Please do not add osteoporosis without further documentation from the physician. I would bring this to your physician's attention and have him add an addenum if there is osteoporosis (or anything else for that matter).
LaSeille Willard, CPC
 
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