Wiki osteophyte after finger fracture

[tag60]

I've been told to code what the provider gives as a diagnosis, but I've also been told they don't always pick the most appropriate code. Here, the provider states certain terms in the body of the note, but then gives a diagnosis that totally threw me. How would you code this? (New provider who is still learning a lot and patient is new to this provider as well.)

S: Osteophyte, finger. Pt had trauma with laceration 1 year ago. Now has a bone spur protruding from finger and wants orthopedic referral.
O: (Nothing pertinent to finger, interestingly enough!)
A/P: Closed fracture of phalanx, 816.00.

I understand that a bone spur could be the result of an injury, so would I then code for injury of finger? I really don't see the fracture supported here (and no previous visits mention of a fracture).

Or is 726.91 (bone spur NOS) what is shown to be the condition documented in this note? (I hate to question the provider's assessment, but sometimes I just have to! I'm just trying to understand, I guess.)

Thanks in advance!

 

[mitchellde]

This would definitely not be coded as a fracture. The provider should be queried regarding the dx of a fracture as a diagnostic statement. Thus looks the ostephyte is a late effect of the fx. To code it as a late effect you would code the bone spur first and the 905.- code second for the late effect of fx. But the provider should be quiried and his attention directed to the late effect codes.