# dx code help



## mabauer1 (Dec 12, 2011)

Hi everyone,

How would you code a case where a 1 year old child came in the ER with a contusion of the forehead and fx of the humerus that occurred after the mother's boyfriend put the child down for a nap.  The only documentation that refers to suspected abuse was the radiologist's report.  The physician's report didn't mention abuse anywhere and no where in the documentation did it indicate that the authorities were notified.  Would you code only for the contusion and fracture or would use of V71.81 be appropriate in this situation?


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## mitchellde (Dec 13, 2011)

You cannot code for abuse that is not documented.  Code for the contusion and the fx only with an E code for unknown if accident.


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## kristyrodecker (Dec 14, 2011)

Code V71.81 describes observation following abuse and/or neglect. Per. the index it is found under Observation, suspected (undiagnosed, unproven), abuse.

Code V71.6 is another similar code found in the index under Observation, suspected, child and/or wife battering. Per. the tabular it can be used for observaiton and evaluaiton for suspected conditions not found.

You may want to consider one of these codes following your injuries but prior to an E code, if documentaiton supports.


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## FTessaBartels (Dec 14, 2011)

*Abuse NOT documented by physician*

If the physician did not document abuse or suspected abuse, then I agree with Debra Mitchell.  Code the contusion and fracture. The best E-code I could come up with would be E849.0 for Accident occuring in private residence. 

The only other option would be to contact the physician to see if s/he wants to dictate and addendum to original report outlining the findings (suspicion of abuse) from Radiologist.  But then, a report would have to be made to authorities. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## mitchellde (Dec 14, 2011)

kristyrodecker said:


> Code V71.81 describes observation following abuse and/or neglect. Per. the index it is found under Observation, suspected (undiagnosed, unproven), abuse.
> 
> Code V71.6 is another similar code found in the index under Observation, suspected, child and/or wife battering. Per. the tabular it can be used for observaiton and evaluaiton for suspected conditions not found.
> 
> You may want to consider one of these codes following your injuries but prior to an E code, if documentaiton supports.



The V71codes are not for suspected conditions, they are for suspected conditions NOT FOUND.  you can only use these codes when documentation supports after study it was  not found.  THE code category nomeclature is a part of the code descriptor as well.  Becareful to notselect codes out of context.


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