Wiki Suspected Fracture Coding

[sorcha48]

I have a provider that used a dx of fracture when the fracture had not been verified as of the day that the visit occured. An x-ray was done and stated no fracture.

I explained that you could not use fracture unless it had been confirmed.

She stated it was "in her opinion" a fracture which was confirmed 2 days later during a CT scan.

She entered in her notes 3 days after the visit.

What should be coded? For the encounter.

 

[mcnaryk]

I have a provider that used a dx of fracture when the fracture had not been verified as of the day that the visit occured. An x-ray was done and stated no fracture.

I explained that you could not use fracture unless it had been confirmed.

She stated it was "in her opinion" a fracture which was confirmed 2 days later during a CT scan.

She entered in her notes 3 days after the visit.

What should be coded? For the encounter.

You are correct-we do not code 'suspected', 'probable' or 'rule-out' diagnosis. See the 10 Steps to Correct Coding in the ICD-9 Guidelines to help prove this to your physician. For the initial encounter, before the CT confirmed the fracture, I would use leg pain (or whatever site it was) with an E code for the cause of injury if known.