ED Coding and Reimbursement Alert

Question: When a patient with a fracture presents in the ED, our practice's current pattern is to wait for x-ray confirmation to report the fracture. If the x-ray comes back negative for a fracture, our coder asks the treating physician to amend his documentation, and claims she does this because she wants to code to the highest degree of certainty. Do we need to keep this up, or can we make a final code decision about the fracture without test confirmation?
       
Arizona Subscriber

Answer: Some fractures the physician can diagnose clinically, such as rib fractures. With other fractures, such as a fracture of the scaphoid bone in the wrist, the physician must diagnose presumptively - meaning the diagnosis is based on mechanism and pain over the bone, with repeat x-rays at a later date required to show the fracture.
 If your emergency department physician legitimately has the clinical impression that a bone is fractured based on mechanism and exam, then coding the fracture diagnosis seems appropriate. The care is generally the same, and the fracture is the diagnosis the ED physician was working with at the time of disposition, and often the radiologist's reading of the x-ray isn't available until the following day.
 
If you are waiting for the confirmatory x-ray and you then know there was no fracture, it would be wrong to assign that code.

 -Reader Questions and You Be The Coder reviewed by Mike Granovsky, MD, CPC, FACEP, vice president of Medical Reimbursement Systems in Stoneham, Mass.