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fracture care - physician service in outpt hospital location

  1. #1
    Default fracture care - physician service in outpt hospital location
    Medical Coding Books
    Q1: What type of documentation would you expect to see in a patient's medical record for fracture treatment without manipulation?

    Q2: Does the below documentation support billing fx care (e.g., 25600-closed tx of distal radial fx w/out manipulation) or an E/M service?

    Hx: A left distal radius injury when fell on outstretched hand and was seen at outside facility and placed in a removable splint. Comes in today for f/up evaluation.
    Physical exam: skin intact on his left distal radius, does have some swelling, minimal tenderness to palpation, brisk capillary refill to fingers, can flex fingers on left hand, has no gross deformity.
    X-ray reviewed: distal radial metaphyseal fracture with apex dorsal angulation with approx 10 degree angulation.

    Assessment: Lest disbal radial metaphyseal fracture.
    Plan: Acceptable alignment, so will place him in a short arrm cast on the left and keep out of athletics for 5-6 weeks.

    *Patient is seen in an outpatient hospital location where the physician does not work for the hospital and will be billing his services through a physicans group practice.
    *Cast is placed by the cast tech who works for the hospital, not the physician.

    References are appreciated.


  2. #2
    yes it does support fracture care without manipulation. It does not matter who actually applies the cast. He is rendering treatment for the fracture and has assumed responsiblity for the care of it.

    Mary, CPC,COSC

  3. #3
    Milwaukee WI
    Default Will do vs did
    I agree with Mary but ...Just one "small" detail ...

    Our compliance dept wants our physicians to document that they actually performed fracture care. This note says "we will place .." That future tense is a no-no for our compliance department. To paraphrase their guidance, "Saying you will do something (plan) is not the same as saying you did it."

    We happen to have a separate "fracture care" sheet that is used to record all the care given, and as long as the attending physician signs/dates that sheet on the first visit we count that as proof that the care that was planned was actually carried out.

    F Tessa Bartels, CPC, CEMC

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