taylov519
Contributor
Here's a summary of the chart note:
Pt crushed his left small finger between two metal objects yesterday while working. He was seen in the ER where he was diagnosised with an open phalanx fracture which was irrigated and closed and he was placed on cephalexin. He is in an AlumaFoam splint today.
Physical exam:
Lt small finger presents with a clean and dry laceration over the dorsum of the small finger over the middle phalanx. The pt has mild swelling and is tender over the middle phalanx. No gross deformity. Neurovascular exam is intact.
Impression:
Open middle phalanx fracture, Lt small finger, status post irrigation and closure in the ER in this pt who is now on p.o. antibiotics with no evidence of infection.
Plan:
We put dressing on the pt's finger, keep him in Alumafoam spint. Light duties at work with no use of Lt hand.
My question is could I bill fracture care for the open fracture, of which the open wound was closed in the ER. OR do I piece bill it as the Pt was a new Pt to us and Doctor is following up? Thanks in advance for any input.
Pt crushed his left small finger between two metal objects yesterday while working. He was seen in the ER where he was diagnosised with an open phalanx fracture which was irrigated and closed and he was placed on cephalexin. He is in an AlumaFoam splint today.
Physical exam:
Lt small finger presents with a clean and dry laceration over the dorsum of the small finger over the middle phalanx. The pt has mild swelling and is tender over the middle phalanx. No gross deformity. Neurovascular exam is intact.
Impression:
Open middle phalanx fracture, Lt small finger, status post irrigation and closure in the ER in this pt who is now on p.o. antibiotics with no evidence of infection.
Plan:
We put dressing on the pt's finger, keep him in Alumafoam spint. Light duties at work with no use of Lt hand.
My question is could I bill fracture care for the open fracture, of which the open wound was closed in the ER. OR do I piece bill it as the Pt was a new Pt to us and Doctor is following up? Thanks in advance for any input.