ED Coding and Reimbursement Alert

Question: When a patient presents with a fracture, we usually get an x-ray confirmation before we report the fracture diagnosis. If the x-ray comes back negative for the fracture, I ask the ED physician to amend her documentation so I can code to the highest degree of certainty. Do I need to keep this up, or can I make a final code decision about the fracture without a test confirmation?


Tennessee Subscriber

Answer: Your answer depends on the kind of fracture the patient has. Physicians can diagnose some fractures clinically, such as rib fractures, whereas other fractures--such as a fracture of the scaphoid bone in the wrist--the physician must diagnose presumptively. Presumptive diagnosis means that the diagnosis is based on mechanism and pain over the bone, and the patient will need follow-up x-rays (probably at an orthopedist's office) at a later date to show the fracture for certain.

If, based on mechanism and exam, your physician legitimately has the clinical impression that a bone is fractured, you should code the fracture diagnosis.