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Diagnosis; left valgus impacted femoral neck fracture

  1. #1
    Modesto, CA; Central Valley Chapter
    Default Diagnosis; left valgus impacted femoral neck fracture
    Medical Coding Books

    The diagnostic statement is left valgus impacted femoral neck fracture.

    My doc is coding 820.02; however, I do not see anything in the notes that state midcervical setion. I was looking at 820.09.

    The OP note:
    At this point, we made appropriate skin marking on the skin and made a small
    approximately 4 cm longitudinal incision. A standard guidewire was in place
    just above the level of the lesser trochanter and drilled along the inferior
    region of the femoral neck. This was shown to me in a center position on both
    the AP and lateral positions. This was then measured to be approximately 90 mm and then the self-drilling sell-tapping screw was placed and with good overall purchase. Two additional screws were then placed in approximately parallel fashion in an inverted triangle type position. One was placed on more central on the AP view and then more anterior on teh lateral view and one was central on the AP view and posterior on the lateral view. These were 90 mm as well and again we utilized the self-drilling self-tapping distally threaded screws.

    Is there something I am missing here? What would the correct diagnosis be?

    Tina Reich, CPC, CPC-I, CEMC

  2. #2
    do you happen to have a radiology report to confirm the doctor's dx, or an H & P or other documentation that supports his dx?

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