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Thread: coding a PX W/O doucumentation (25600)

  1. #1

    Default coding a PX W/O doucumentation (25600)

    AAPC: Back to School
    Does anyone have a supporting documentaion link that states the physcian needs to document all surgeries, even if it is a closed reduction ( Treatment) of distal radial FX? I have a doctor that wants me to bill this without documenting it. He did a brief inpatient consult (99251) and stated he applied the patient in a cast and to F/U with him in four weeks. When the patient did come back in 4 wks he charged a new PT visit, when in essence it should have been a P/O visit if he did a closed reduction. To me, the consult should be coded and the cast only. Where is the information for me to code the closed reduction (25600)? His response was I should be able to determine what he did by looking at the DX from the xray report.
    I don't know about you, but the way I was trained, if it is not documented, it never happened.

  2. #2
    Join Date
    Apr 2007
    Hartford, CT


    25600 is closed treatment of a distal radius fracture, not a closed reduction (25605). If the M.D. stated that he applied a cast, this is closed treatment and can be billed. However, it has a 90 day global period and he would not be able to bill a new patient visit when the pt came to the office for follow-up.

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