occult fracture

ls0403

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I need some opinions please!! Physician charged closed treatment but I'm not sure about the wording "she likely has an occult fracture" and "questionable irregularity of the radial neck". Is this enough to consider diagnosis definitive or would you lean toward coding the symptoms and no fracture charge?

Thanks,
Lisa

See excerpt of note below...


HPI: The patient is a 51-year-old female, who presents today for evaluation of right forearm pain. She is seen in consultation with Dr. X. She notes that her pain began after a fall on August 20. The pain is located over the dorsal aspect of the forearm. She does feel some tenderness proximally into her elbow. She is able to move her elbow, but states that it feels somewhat stiff. No numbness or tingling distally. She has mild wrist pain.

X-ray: X-rays of the elbow reveal questionable irregularity of the radial neck. There is an anterior and posterior fat pad sign.

Plan/Assessment: I discussed with the patient that she likely has an occult proximal radius fracture. Typically, these can be treated nonoperatively, and she can use a sling for the first week or so after this injury. She should have a follow-up x-ray to ensure that she is not losing alignment of her fracture. She lives in XXX, and will follow-up with an orthopedist there. Once comfortable, she should pursue range of motion exercises out of the sling.
 

mbort

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The only problem I have with my decision making process on this one, is that later in the note the doc calls it a fracture. Maybe get clarification from the doc?? I hate when they do that!!
 

milant

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I agree with getting confirmatin from the doc. We are always told not to code from probable, suspect etc. I believe "likely" would fit into that category. I would ask the doc for a more definite dx.
 

dmaec

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I don't see it as fracture treatment at all, not even if you query the provider, that assessment has already been given. I see it as pain and an E/M level.
I'd code the pain and an E/M level (whatever documentation supports). The patient will be following up with an ortho doc in her own area. The ortho doc will provide definitive fracture treatment (apparently) if needed. The patient in this case comes in with pain, has an xray, (it's not definitive), she's placed in a sling (for comfort) and will follow up with an ortho in her own area. I wouldn't code a fracture treatment code knowing so far, it's only possible that it's fractured and she is being sent to an ortho for more definitive treatment of that "possible" fracture and POSITIVE pain symptoms.

{that's my opinion on the posted matter}
 

jharrell

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I agree with dmaec, because not only is it a likely fracture, but you are sending to Ortho and I have always been taught that you can't charge a fracture care code if you send to Ortho. Because you will not be doing any of the follow treatments for this pt, and the Ortho will charge it.

Hope this helps,
Jessica Harrell, CPC
 
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Devil's advocate

The note seems to indicate that the patient lives in a different city than where this care was performed ... She lives in XXX, and will follow-up with an orthopedist there.

You CAN bill for fracture care if you are sending the patient to follow-up with an orthopaedist in their home town. We do it all the time ... child visiting grandparents breaks arm here in Milwaukee - we bill the fracture care with 54 modifier - and send child home to wherever USA to follow with orthopaedist there, who presiumably will bill fracture care with 55 modifier.

However, In THIS case, I'd only bill the E/M because you only have a "likely" fracture - no definitive fx diagnosis.

F Tessa Bartels, CPC, CPC-E/M
 
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