Occult Fracture

roneal72

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Hello all- I have a question regarding the dx of occult fracture:

If the documentation states

X-RAYS: x-rays were reviewed. multiple views showing no obvious fractures or dislocations

PLAN: Put him in a long arm cast for several weeks. We will see him back for cast removal, physical exam, and x-rays multiple view of the elbow. At this point his diagnosis is an occult fracture of the right medical epicondyle.

Would I code the diagnosis as a fracture or elbow pain? The ICD-9 states to code signs and symptoms if the dx is not known so this leads me to believe the correct code would be for elbow pain but would like another opinion.

Thanks for your assistance!
 

dclark7

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I would code the fracture of medical epicondyle. An occult fracture is one that does not show up on x-ray. Your doc must have had enough clinical signs to warrant this dx, but when in doubt, you should check with the doc.
 
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