TTcpc
Guru
Hello,
I'm having a difference of opinion with a colleague regarding whether a closed fracture goes from an acute uncomplicated injury to a self-limited or minor problem just because it is healing and doesn't need to have a cast replaced or braced. My colleague is stating that once the provider states it's healing and no immobilization is need that it "converts" from an injury to a self-limited problem.
To clarify, I am not stating that the visit should necessarily be a 99213 on the number/complexity of problems alone as there was not sufficient supporting information in the data or risk to support the 99213; however I feel the incorrect credit is being given under the number and complexity of problems addressed section. I am wanting to clarify as there are occasions where my providers will state the fracture is healing, instruct the patient/parent to leave a brace on a little longer for additional support to the healing fracture area and then instruct them that they can remove it within 1-2 weeks or wear only during the day/activities, etc. - my colleague states it can still be counted as an acute uncomplicated injury in these situations simply because we are instructing them to use the brace a little longer even though the site is healing and we're not following up - but if we don't instruct continued use of the brace it suddenly becomes a self-limited problem - to me it's still an injury. Also, depending on the fracture site even though bracing is d/c'd that we may continue to follow for any growth plate healing issues/complications.
Here's one of the scenarios we're disagreeing on: We're a pediatric ortho practice , our PA sees a patient for a closed physeal fracture of the lower end of the radius - 1st visit on 6/28/2022 and had 3 follow-up visits (including the final one in question here) and up until this last visit the patient continued to complain of tenderness over the fracture site and went from casting to brace and on this last visit released from needing either. The provider did not bill fracture care global but opted for itemized billing. The PA states in her assessment on this last visit that "The fracture has continued to heal and to remodel. Is difficult to see the fracture line. He is able to put his full weight on it was right wrist. He does have full symmetric range of motion. His fracture does not involve the growth plate. He will therefore follow-up in the clinic on an as-needed basis."
I am not able to find anything that supports that an injury "converts" to a self-limited problem just because we're not doing casting/bracing any longer. To me the condition was an injury and per the AMA guidance an acute, uncomplicate injury is "Acute, uncomplicated illness or injury: A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness. Examples may include cystitis, allergic rhinitis, or a simple sprain." So to me it reads that treatment may not necessarily required but is taken into consideration and on this last visit it was deemed by the PA as not needed as the fx site tenderness had resolved since last visit - but that doesn't mean that the fracture "went away" it's still healing, just not requiring mobilization.
Your thoughts/opinions would be greatly appreciated!
I'm having a difference of opinion with a colleague regarding whether a closed fracture goes from an acute uncomplicated injury to a self-limited or minor problem just because it is healing and doesn't need to have a cast replaced or braced. My colleague is stating that once the provider states it's healing and no immobilization is need that it "converts" from an injury to a self-limited problem.
To clarify, I am not stating that the visit should necessarily be a 99213 on the number/complexity of problems alone as there was not sufficient supporting information in the data or risk to support the 99213; however I feel the incorrect credit is being given under the number and complexity of problems addressed section. I am wanting to clarify as there are occasions where my providers will state the fracture is healing, instruct the patient/parent to leave a brace on a little longer for additional support to the healing fracture area and then instruct them that they can remove it within 1-2 weeks or wear only during the day/activities, etc. - my colleague states it can still be counted as an acute uncomplicated injury in these situations simply because we are instructing them to use the brace a little longer even though the site is healing and we're not following up - but if we don't instruct continued use of the brace it suddenly becomes a self-limited problem - to me it's still an injury. Also, depending on the fracture site even though bracing is d/c'd that we may continue to follow for any growth plate healing issues/complications.
Here's one of the scenarios we're disagreeing on: We're a pediatric ortho practice , our PA sees a patient for a closed physeal fracture of the lower end of the radius - 1st visit on 6/28/2022 and had 3 follow-up visits (including the final one in question here) and up until this last visit the patient continued to complain of tenderness over the fracture site and went from casting to brace and on this last visit released from needing either. The provider did not bill fracture care global but opted for itemized billing. The PA states in her assessment on this last visit that "The fracture has continued to heal and to remodel. Is difficult to see the fracture line. He is able to put his full weight on it was right wrist. He does have full symmetric range of motion. His fracture does not involve the growth plate. He will therefore follow-up in the clinic on an as-needed basis."
I am not able to find anything that supports that an injury "converts" to a self-limited problem just because we're not doing casting/bracing any longer. To me the condition was an injury and per the AMA guidance an acute, uncomplicate injury is "Acute, uncomplicated illness or injury: A recent or new short-term problem with low risk of morbidity for which treatment is considered. There is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. A problem that is normally self-limited or minor but is not resolving consistent with a definite and prescribed course is an acute, uncomplicated illness. Examples may include cystitis, allergic rhinitis, or a simple sprain." So to me it reads that treatment may not necessarily required but is taken into consideration and on this last visit it was deemed by the PA as not needed as the fx site tenderness had resolved since last visit - but that doesn't mean that the fracture "went away" it's still healing, just not requiring mobilization.
Your thoughts/opinions would be greatly appreciated!