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Closed trmt of fx's performed in the office setting

  1. Smile Closed trmt of fx's performed in the office setting
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    I was just wondering what kind of verbage is required for my docs to perform closed trmt of fx's in the office setting? I know closed trmts can easily consisit of splintting, strapping or casting. However if the doctor is charging a 27750 and the documentation states:

    male with Left leg pain after a fall 2 days ago. He was seen in the ED where XR were taken and he was shown to have a minimally displaced tibial shaft fx. He has been NWB in a posterior splint with minimal discomfort.

    Assessment: Left tibial shaft fracture

    Plan: Images and dx reviewed with father. Long leg splint placed today and he will RTC in 7 days to change into a long leg cast. Possiblity of future growth plate abnl also d/w with his father.

    Does documentation suffice? I'm thinking simple can the verbage be? Any feedback would be greatly appreciated!

    Have a great day!

  2. #2
    Capital Coders, Columbia, SC
    Believe it or not, it can be this simple. In a 27750, the physician treats the fracture without any manipulation, and typically applies a splint/cast/brace. It appears that this is what he/she has documented. Welcome to the global period.

    Bill Hale, CPC

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