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Fracture Diagnosis

  1. Default Fracture Diagnosis
    Clearnace Sale
    Patient has had a wrist x-ray to rule out a fracture. No other symptoms have been provided. The impression on the report reads scaphoid fracture of indeterminate age. The body of the report refers to this fracture as likely to be chronic.

    Any suggestions on the correct diagnosis for this scenrio?

    Thank you

  2. #2
    Gulf Coast - GCAPC
    Well you can't pay any attention to the verbiage "likely to...". So you would have to just use 'scaphoid fracture' and also not use 'indeterminate age', and since it isn't open (otherwise doc wouldn't have to 'rule out' - which is a no-no for outpatient coding).. you'd probably use 814.01. If you're in a facility and this is outpatient x-ray... you'll need to get with the doctors office to get a better admitting diagnosis, like wrist pain or wrist injury.

    What do others think? Am I on the right track?
    Rhonda Winder, CPC

  3. #3
    I would go with the impression "scaphoid fracture" as the diagnosis.

  4. #4
    Duluth, Minnesota
    fisherd - I agree with rmwinder & mbort - go with coding the fracture. I would code also the pain...but I see you say nothing else was mentioned so you can't code the pain in this scenario. (usually, pain is involved somehow when it comes to fracture xrays)
    {that's my opinion on the posted matter}

    rmwinder, you're definitely on the right track ! (but good luck in getting those better dx's - we've been trying for years!) ... when all else fails, you just end up going back to the doc for clarifications of dx's.
    Donna, CPC, CPC-H

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