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CT Upper Extremity....? correct dx code

  1. #1
    Default CT Upper Extremity....? correct dx code
    Exam Training Packages
    HISTORY: Fracture distal radius, recheck

    IMPRESSION: Partial healing of previously noted distal radial fracture since prior exam although residual defects remain.

    Should this be coded as a current fracture since there is only partial healing or V54.89


  2. #2
    I would code as a current fracture due to the fact that there is only partial healing. If it had said healed, then I would have used the V54.89.

  3. #3
    Default correct dx code
    I would use the V54.89.
    According to the coding guidelines: traumatic fractures are coded while the patient is receiving active treatment for the fracture. Examples: surgical treatment, emergency department encounter, evaluation and treatment by a new physician. Fractures are coded using the aftercare codes (subcategories V54.x)for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase. --CPT 2009 coding guidelines page 14 #1).

    Anyone else?

  4. #4
    Hartford, CT
    I would use V54.11, Aftercare for healing traumatic fracture of the upper arm. This is more specific than V54.89 and if you feel confident enough to use a current fracture code (8XX.XX) I'd go with the specific body area for the V code.

  5. #5
    Default correct dx
    I like the V54.11 better too.

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