# Coding fractures when x-rays are negative



## lsmft (Sep 8, 2009)

How do you code a case with the diagnosis sheet states various and multiple fractures and every x-ray is completely normal?  I know I've seen this somewhere but cannot find it.


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## mitchellde (Sep 8, 2009)

Your codes come from physician documentation, the radiologist is a physician and has rendered a dx, unless you have something from the attending physician that disputes that then code from the radiology note.  A dx sheet is not the same as the attending physician note.  Ife the radiologist report is normal what does he indicate as the reason for the exam?  You might be able to use a V71.x dx code which is  a first listed only code.


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## lsmft (Sep 8, 2009)

The only reason the radiologist lists is pain in the various areas xrayed and ALL findings are completely normal. Yet the prescribing physician states there are fractures in all these areas.

I can code the pain in the areas x-rayed but what about coding fractures when there are none??


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## mitchellde (Sep 8, 2009)

I would code the pain only, I would need to see the actual physician note as to why he is saying fracture.  It really makes no sense.  Sometimes I have observed that the physician will document the possibility of fracture or that areas are consistent with fracture, and this sll indicates uncertainty which cannot be coded.  I have never observed documentation of fracture when diagnostic confirmation is not there.  Is it possible this is an aftercare encounter for fractures that have healed?  If so there is a coded for healed fracture V67.x or healing fracture V54.x.


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## lsmft (Sep 8, 2009)

Thanks it helps to have your advice. For some reason the physicians here code fractures when they aren't there...an ongoing issue. I appreciate your reply very much!


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## LTibbetts (Sep 8, 2009)

We have the same problem here in our ER. The physician uses a fracture dx but the radiologist that reads the x-ray claims no fracture. Whenever we query the physician, they stick with their dx of a fracture since they are treating it as if it were and the fracture care is the same. We are having an ongoing issue with that here.


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