Please need your assistance...Thank you....
Would the following apply ~meaning only bill an em/57 and cast even though closed reduction seemed to fail and decided sugery?
Billed: 6/2/10-99223 & 27818
Visit of 6/2/10-
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old female complaining of right ankle injury. The patient had tripped over a puppy today injuring her right ankle. She had immediate pain and inability to ambulate. She is brought to White Plains Hospital Emergency Room. X-rays showed a fracture. She has a history of hypertension. She lives in Florida and she has a visiting her family in New York for her grandson's graduation. She is a previous independent community ambulator.
PHYSICAL EXAMINATION: Physical exam shows elderly white female lying in a hospital stretcher in mild distress. Right ankle has posterior deformity and pain with range of motion. There is tenderness. She is actively move her toes. Vascularity is good and skin is intact. There is generalized tenderness.
X-rays of the right ankle show trimalleolar fracture with posterior subluxation of the talus. Intravenous sedation was given and closed reduction was performed but the ankle was noted to easily sublux posteriorly after reduction. A short leg fiberglass cast was applied with attempt to hold the reduction. Post reduction x-rays of the right ankle showed continued posterior subluxation of the talus in the trimalleolar fracture. Right trimalleolar ankle fracture subluxation. After risks and benefits of surgery versus nonoperative treatment were discussed with the patient she wished to proceed with surgery for open reduction and internal fixation of the right ankle. Informed consent was obtained for surgery with risks explained including but not limited to infection, blood loss, neurovascular injury, failure of fixation and posttraumatic osteoarthritis. She understands and is willing to proceed. The patient will get medical evaluation for clearance for surgery. The patient is NPO after midnight tonight for possible surgery tomorrow. The patient will elevate her ankle take analgesics as necessary. Cast was bivalved to accommodate any swelling. Please refer to the medical doctor's consult for the remainder of the history and physical examination.
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join