Medical Documentation /Suspected Stress Fracture
Our podiatrist saw a patient for follow up of foot pain. He took x-ray's and documented
" Findings: No overt fracture or bone pathology is noted. There is a possible transverse fracture line at the base of the 3rd metatarsal--this would correspond to where erythema is noted on the dorsum of the foot. No other bone pathology is noted"
"Exam indicates Musculoskeletal:Noted for erythema and swelling over the dorsum of the right foot--most intense erythema is noted over the 3rd / 4th metatarsal base.Noted for well-healed bunionectomy scar over the dorsum of the first MTP joint bilaterally. There is a slight abductus noted related to the right hallux. ROM of both first MTP joints is good, without pain."
Further in Discussion: he indicates "suspected Stress Fracture ", but in diagnosis he codes it as 733.94 with no further clarification of the reason for the medical decision.
I felt the medical documentation did not warrant the diagnosis since it was noted as suspected, and suggested he code as signs/symptoms. The doctor disagreed stating that he determined it was a fracture based on his exam. Is the documentation noted enough to support the diagnosis ?
Our podiatrist saw a patient for follow up of foot pain. He took x-ray's and documented
" Findings: No overt fracture or bone pathology is noted. There is a possible transverse fracture line at the base of the 3rd metatarsal--this would correspond to where erythema is noted on the dorsum of the foot. No other bone pathology is noted"
"Exam indicates Musculoskeletal:Noted for erythema and swelling over the dorsum of the right foot--most intense erythema is noted over the 3rd / 4th metatarsal base.Noted for well-healed bunionectomy scar over the dorsum of the first MTP joint bilaterally. There is a slight abductus noted related to the right hallux. ROM of both first MTP joints is good, without pain."
Further in Discussion: he indicates "suspected Stress Fracture ", but in diagnosis he codes it as 733.94 with no further clarification of the reason for the medical decision.
I felt the medical documentation did not warrant the diagnosis since it was noted as suspected, and suggested he code as signs/symptoms. The doctor disagreed stating that he determined it was a fracture based on his exam. Is the documentation noted enough to support the diagnosis ?
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