# level of risk - definitive care



## Nancy (Jun 15, 2009)

I am in need of opinions to help settle a dispute, please.

Going solely on the basis of diagnosis...what level of risk would you give to a closed fracture of 3 metatarsals that were splinted in the ED and referred to orthopaedics for definitive care?

Thanks in advance!!!!


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## Joe_coder07 (Jun 15, 2009)

Hi,

My opinion on this is we go with level-3 for risk of fracture... & for splinting &  refer to ortho... I dont think they dont have much work up in er for this senario...


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## FTessaBartels (Jun 16, 2009)

*Based on limited info*

Based on the limited info you provided ... LOW risk (acute, uncomplicated injury)

F Tessa Bartels, CPC, CEMC


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## LLovett (Jun 16, 2009)

Based on dx only I agree with Tessa.

Why only on dx? The dx points should be 4 and I would think they would have gotten a Rx pain med which would be moderate.

Just my thoughts,

Laura, CPC


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## maysons1703 (Jun 16, 2009)

*it depends*

Well it all depends
MDM is determined by 3 categories

Presenting Problem=Low (acute, uncomplicate illness)
Diagnostic test,etc.= xray (straightforward)
Mananagement Options= rx managment (prescription pain meds, which I am confident they gave)=moderate or ***OTC medicine, like motrin is Low

The highest overall level determine the risk, so if Rx was given the risk is moderate. I don't have the CMS guidelines in front of me, so you may want to check to seen where the splint and xray falls in the risk category.

Melissa Freeman, RHIT,CCS-P,CPC


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## Nancy (Jun 18, 2009)

I realize there are 3 components to MDM, of which you need only 2.  My question, basically, is where in the table of risk, do you consider a closed fracture?  A "simple sprain"  is considered low risk; a breast lump is moderate; a PE is high..... What level is a closed fracture?


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## Anna Weaver (Jun 19, 2009)

*table of risk*

According to the table of risk, it says closed treatment of fracture or dislocation, without manipulation is listed under moderate risk.


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## Nancy (Jun 19, 2009)

thanks, Anna!!!


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## FTessaBartels (Jun 19, 2009)

*Agree with Anna ...BUT*

I agree with Anna that closed *treatment* of a fracture is moderate risk, but the original question didn't mention that the fracture was treated. The original question only asks where to assign risk for the *diagnosis* of the closed fracture.

Frequently in the ER the fracture is NOT treated ... patient is perhaps splinted and then referred to an ortho specialist for treatment.

So if there's no treatment, the *diagnosis *of closed fracture would be LOW risk (acute, uncomplicated injury)

Hope that helps,

F Tessa Bartels, CPC, CEMC


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## Anna Weaver (Jun 22, 2009)

*level of risk*



FTessaBartels said:


> I agree with Anna that closed *treatment* of a fracture is moderate risk, but the original question didn't mention that the fracture was treated. The original question only asks where to assign risk for the *diagnosis* of the closed fracture.
> 
> Frequently in the ER the fracture is NOT treated ... patient is perhaps splinted and then referred to an ortho specialist for treatment.
> 
> ...




Just a question then, you don't consider splinting with referral to ortho a treatment? I understand it's not fracture care, but they did treat. So, is the wording only for fracture care? I'm not trying to be argumentative, I'm trying to understand the reasoning.


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## mitchellde (Jun 22, 2009)

I am agreeing with Tessa.  Usually in the ER when they splint and referr on to ortho, the splinting is not strictly fx care it is to afford some comfort to the patient and to avoic further injury.  So it is not considered fx care.


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## Lisa Bledsoe (Jun 22, 2009)

Hi All - jumping in here a little late, but I would consider the level of risk as moderate simply because there are 3 fractures and they are stabilizing until ortho provides definitive care.  To me, the stablization is treatment.


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## ARCPC9491 (Jun 22, 2009)

I need more details about the fracture itself in order to give my opinion. What kind of fracture? Closed, I know that. But were they broke in half? or shattered? or multiple fractures to the same bone? Does the ED think surgical intervention is required? thus resulting in the referral to ortho? I agree that "splinting" prevents further injury, doesn't necessarily treat the fracture itself unless the bone was placed back to its original position and then immobilized. Most times immobilization is the only treatment needed for a simple fracture. but was this a simple fracture? I'm guessing no. As soon as a bone is broken, the bone begins to grow back immediately, whether it's displaced or not. (I personally broke my pinky finger years ago, never had it treated, and I can't bend it all the way because it grew back together the way it was when it was broken) So, this leads me back to my original question, if the ED did not manipulate anything, why would they put a splint on? If for injury prevention, until the patient saw ortho, I would not consider this "moderate risk" This is why we need 2/3 to determine the overall medical decision making. More info please


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## Lisa Bledsoe (Jun 22, 2009)

I still say splinting (aka closed _treatment_) of the *fracture(s)* is moderate in the table of risk.  It states "*closed treatment of fracture or dislocation without manipulation".  *


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## Anna Weaver (Jun 22, 2009)

*level*



Lisa Curtis said:


> I still say splinting (aka closed _treatment_) of the *fracture(s)* is moderate in the table of risk.  It states "*closed treatment of fracture or dislocation without manipulation".  *



I agree. They did a treatment. It might not be fracture care, but it's still treatment without manipulation of a fracture. They did a splint and referred to ortho. 
So, as in most things coding---We have a split vote! LOL. It's one of those gray areas in our black and white world.


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## Lisa Bledsoe (Jun 22, 2009)

Oh so true Anna!!


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## LLovett (Jun 23, 2009)

*Go back to the original question*

Treatment is under management options. We were asked what the Dx (ie presenting problem) would fall under on the table of risk. Several of us pointed out that there are other things to consider when leveling risk. 

Also, if they gave them an ice pack and told them to follow-up with ortho would you give credit for moderate risk? That is a treatment as well. 

To me, when they say treatment of fracture, they are giving you credit for taking on the care/outcome of that fracture. Which in this case they would not be. 

Just my opinions but I thought it should be pointed out that the question asked was not what caused the differing view points.

Laura, CPC


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## rthames052006 (Jun 23, 2009)

katmryn78 said:


> Treatment is under management options. We were asked what the Dx (ie presenting problem) would fall under on the table of risk. Several of us pointed out that there are other things to consider when leveling risk.
> 
> Also, if they gave them an ice pack and told them to follow-up with ortho would you give credit for moderate risk? That is a treatment as well.
> 
> ...



Great comeback Laura...

After reading this thread, I agree with your comments.


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## Lisa Bledsoe (Jun 23, 2009)

katmryn78 said:


> Treatment is under management options. We were asked what the Dx (ie presenting problem) would fall under on the table of risk. Several of us pointed out that there are other things to consider when leveling risk.
> 
> Also, if they gave them an ice pack and told them to follow-up with ortho would you give credit for moderate risk? That is a treatment as well.
> 
> ...




You are correct, they would not be taking on fracture care treatment...that would take us out of E/M all together.  

As far as just looking at the presenting problem section of the table of risk - do we then consider 3 closed fractures uncomplicated or complicated?  Are they self-limited/minor?   Does "3 closed fractures" indicate the same level of a presenting problem as the example of "simple sprain"?  Do we have an uncertain prognosis?  All good points in this thread.  All good things to consider.  Excellent discussion for our profession.  I have the utmost respect for all opinions here, and respectfully stand by my *opinion*.


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## rthames052006 (Jun 23, 2009)

Lisa Curtis said:


> You are correct, they would not be taking on fracture care treatment...that would take us out of E/M all together.
> 
> As far as just looking at the presenting problem section of the table of risk - do we then consider 3 closed fractures uncomplicated or complicated?  Are they self-limited/minor?   Does "3 closed fractures" indicate the same level of a presenting problem as the example of "simple sprain"?  Do we have an uncertain prognosis?  All good points in this thread.  All good things to consider.  Excellent discussion for our profession.  I have the utmost respect for all opinions here, and respectfully stand by my *opinion*.



Lisa,

Your right, this is a wonderful discussion and with us all adding our two cents makes you stop to think what another is thinking.  I always like these types of discussion because I feel that we always take something from it.

Have a great day!


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