Wiki Partial Excision of fibula

[cjavorsky]

I always get stuck on coding a partial excision of fragment from distal fib. It's the diagnosis that is hard for me. All the physician dictates is "X-rays include AP, lateral, and mortise ankle, which show large fragmentation distal fibula where he has focal tenderness, with no significant calcific tendonitis of the Achilles. Stress views on the ankle show no significant widening of the tibiotalar joint."

Any hints or help would be appreciated!

Thank you!

 

[MI_CODER]

Without seeing the op report, I would suggest looking at the following codes to see if any of these would fit your scenario:

1. Fracture codes - I use 3M and when I type in "fragmentation" it takes me to the fracture codes. Is there any documentation (H&P, op note, etc) to support that this was a fracture? I would suggest querying the provider and asking if this was indeed a fracture and if it was traumatic or pathologic.

The following two codes I don't really like because they're pretty vague but I feel that these could be used if you either can't query the provider and/or don't have any other documentation to go off of..

2. Other specified bone disorder (M89.8X6)
3. Abnormal findings on diagnostic imaging of other parts of musculoskeletal system (R93.7)

 

[cjavorsky]

Thank you so much for helping me out. My physician is the worst at dictating, always very vague and when I go to him its always, eye rolling and big shoulder shrugs and he says I'm to "persnickety"!
I will then go to the MRI/CT and see what the assessments are on those reports.
Thank you again!

 

[MI_CODER]

You're welcome and I completely understand. I think we all have those providers that aren't exactly the best at documenting. I would take being "persnickety" as a compliment because that means you're doing your job as a coder. Sometimes I wish providers would realize that we aren't just trying to annoy them and in fact are on their side and are just making sure that their documentation would be able to withstand an audit.