Advanced Search

Revenue Cycle Insider

General Surgery Coding:

Don’t Report an Open Fracture Repair Code Without Documentation

Published on Mon Mar 30, 2026

You’ve reached your limit of free articles. Already a subscriber? Log in.

Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:

Simple explanations of current healthcare regulations and payer programs
Real-world reporting scenarios solved by our expert coders
Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
Instant access to every article ever published in Revenue Cycle Insider
6 annual AAPC-approved CEUs
The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more

Other Articles of

March 2026

Practice Management:
Understand How to Use RVUs to Establish a Practice Fee Schedule
Don’t forget to reassess your fee schedule to make sure it reflects your practice. With [...]

ICD-10-CM Coding:
Boost Your Confidence in Reporting Additional Diagnoses
Hint: Remember to reference different parts of your code book. Coders may feel confident selecting [...]

Podiatry Coding:
Don’t Freeze When It Comes to Coding Plantar Wart Destruction
Question: I have a report for a patient who presented to the podiatrist with a [...]

General Surgery Coding:
Look to 11102 for a Shave Biopsy
Question: A new patient with a lesion on their lip presented to a dermatologist’s office. [...]

General Surgery Coding:
Don’t Report an Open Fracture Repair Code Without Documentation
Question: A patient came in for surgery to repair a percutaneous intra-articular proximal phalanx head [...]

Anesthesia Coding:
Find the Light at the End of the Tunnel With Esophagoscopy Procedures
Procedure purpose is key when choosing the correct anesthesia code. Esophagoscopy cases are incredibly common, [...]

Pediatric Coding:
Patient Age Is Key When Coding Conjunctivitis
Question: We recently saw a 6-day old infant who presented with discharge from both of their [...]

Podiatry Coding:
Is Buddy Taping the Same as Strapping Toes?
Question: A patient presented with a suspected broken toe. They stubbed their left big toe [...]

Primary Care Coding:
Impress With Your Pressure Ulcer Coding Skills
Question: We recently had a patient visit our office who was suffering from pressure ulcers [...]

Compliance:
Counting This Work Toward ‘Time’ Is a Compliance Red Flag
Question: I’ve recently started at a practice and think one of the providers must be [...]

Neurology & Pain Management Coding:
Prevent Inaccurate Stroke Coding FAST
When a patient displays these four symptoms, stroke is a real possibility. When a patient [...]

Optometry/Ophthalmology Coding:
Is Modifier 62 Needed When 2 Different Surgeries Take Place?
Question: I have procedure notes for two different ophthalmological surgeries for the same patient that [...]

Orthopedic Coding:
Are Ganglion Cyst Claims Draining You?
Question: A new patient visited the office to have a ganglion cyst of the ankle drained. [...]

General Coding:
Keep Your Queries Clinical
Question: Can I mention coding guidelines directly when querying a physician? I feel like it [...]

Neurosurgery Coding:
Consider Additional Dx Code for These Abscesses
Question: Encounter notes indicate that a patient suffers from “cerv spinal cord abscess/methicillin-resistant Staph infection.” [...]

Optometry/Ophthalmology Coding:
Use This Guide to Identify the Correct AMD ICD-10-CM Codes
Do you need multiple codes for separate AMD diagnoses in each eye? Age-related macular degeneration [...]

E/M Coding:
Look to NPI Choice for Split/Shared Signature Requirements
Question: In our facility, a nurse practitioner (NP) works in tandem with a physician, and [...]

Compliance:
Understand the ‘Circle of Life’ for Auditing to Tell the Whole Story
Check in on the systems in place that provide the foundation for coding. Auditing is [...]

Medicare Regulations:
Patient Representatives Can Be Appointed, if Necessary
Question: One of our patients, a 95-year-old widowed Medicare beneficiary who has terrible arthritis and [...]

ICD-10-CM Coding:
Look to Table of Neoplasm Neuroblastoma Coding
Question: How do I find the correct code for a neuroblastoma diagnosis? The documentation says [...]

Neurology & Pain Management Coding:
Choose CRPS II Code With Causalgia in Mind
Question: Encounter notes indicate that a patient suffers from “CRPS II.” I see codes for [...]

Orthopedic Coding:
Need Some Practice With Your Knee Replacements Claims?
Keep detailed notes if conservative treatments have failed in the past. Total knee replacements (TKRs), [...]

Path/Lab Coding:
Take This Advice to Accurately Report Bone Marrow Specimen Codes
Question: When we get bone marrow specimens from surgical procedures, the surgeon usually sends them [...]

Urology Coding:
Analyze Documentation to Determine Your Adrenalectomy Code
Use modifiers to indicate laterality. Adrenal glands are the organs located above the kidneys, which [...]

Technology & Innovation in Healthcare:
Rectify Clinical Trial Enrollment Headaches With AI-Assisted Screenings
Learn how RECTIFIER streamlines clinical trial enrollment screening. Manually screening patients for clinical trial eligibility [...]

Otolaryngology Coding:
Pick Other, Unspecified Otosclerosis Codes Confidently
Question: What is the difference between H80.8- and H80.9-? Revenue Cycle Insider Subscriber Answer: Code [...]

Otolaryngology Coding:
Take a Deep Dive Into Neck Dissection Coding
Beware bundling issues with total laryngectomies and glossectomies. Neck dissections are procedures intended to remove [...]

General Coding:
Remember These Best Practices When Coding Hospice Claims
Hint: Coders should look to medical directors for information on related conditions. Hospice regulations have [...]

In Case You Missed It (RCI Bonus Content):
Take Note of These April 1 HCPCS Level II Code Changes
Learn about the HCPCS Level II quarterly update. The Centers for Medicare & Medicaid Services [...]

General Surgery Coding:
Dig Into Documentation for Burn Encounter Specifics
Hint: Not all burn visits will warrant a code from the 16000 series. When burn [...]

Emergency Department Coding:
7 FAQs Lead You to Cerumen Removal Coding Success
Hint: If it’s not impacted, report an E/M code. When a patient comes to the [...]

Technology & Innovation in Healthcare:
Can Providers Overcome Real-World Wearable Device Implementation Challenges?
Question: I read the February 2026 Revenue Cycle Insider article, “Unlock Access to Wearable [...]

Urology Coding:
Learn Which Code to Assign for a Varicocele Diagnosis
Question: A patient presented to the urologist with pain in their scrotum. The urologist performed [...]

Otolaryngology Coding:
Mind This Modifier for Post-Septoplasty Nasal Debridement
Question: A patient with a deviated septum underwent a septoplasty. We followed up the following [...]

Emergency Department Coding:
Check Matrix Involvement When Making Avulsion/Excision Decision
Question: When the emergency department (ED) physician removes a patient’s toenail, what is the correct [...]

Medicare Regulations:
Make Preparations for New Version of the Outpatient Observation Notice for Medicare
Question: I understand there is a new Medicare Outpatient Observation Notice (MOON) that we will [...]

ICD-10-CM Coding:
Report 2 Codes for Chronic, Bilateral Pulmonary Emboli
Question: A provider documented that a patient has chronic bilateral subsegmental pulmonary emboli (PE). What is [...]

Optometry/Ophthalmology Coding:
Nail Down This Nuclear Sclerosis Coding Case
Question: A patient presented with complaints of blurry vision in their left eye. The ophthalmologist [...]

Oncology/Hematology Coding:
Use This Guide to Decode Oncology Infusion Administration Coding
Understand documentation requirements, administration codes, infusion timing, and more. Oncology infusion coding is often complex [...]

Practice Management:
Consider How Patients Perceive Your RCM Notification Choices
Question: I think sending bills to patients via their preferred communication type makes sense, but [...]

Urology Coding:
Get to Know the Different CKD Stages
Question: I have a report where the urologist diagnosed the patient with chronic kidney disease [...]

Diagnostic Radiology Coding:
Learn to Code a Fixation Device That’s No Longer Fixed in Place
Question: I have a report for a 42-year-old patient who presented with left ankle pain. [...]

Path/Lab Coding:
Follow This Guideline for ‘Consistent With’ Dx
Question: A patient presented to a provider’s office with a painless lump behind their ear. [...]

Diagnostic Radiology Coding:
Know When Imaging Guidance Is Included in the Procedure
Question: I have an operative note for a peripherally inserted central venous catheter (PICC) insertion [...]

Emergency Department Coding:
Check for Critical Care Before Reporting CPR With E/M
Question: A patient is brought to the emergency department (ED) in cardiac arrest. The ED [...]

Primary Care Coding:
Avoid a Denial When Performing Multiple PFTs
Question: The practitioner performed a pulmonary function test (PFT) twice on the same date of service [...]

Neurosurgery Coding:
Fit Modifier FT Into Certain Critical Care Claims
Question: I have heard that I should use modifier FT whenever a Medicare patient receives [...]

Oncology/Hematology Coding:
Pinpoint Cause for Correct Chemotherapy Fatigue Reporting
Question: A patient with cancer reported to our oncologist complaining of fatigue. The provider documented [...]

Gastroenterology Coding:
Code Gastritis With H. Pylori Confidently
Question: I have a patient record where the gastroenterologist documented the diagnosis as chronic gastritis [...]

Pediatric Coding:
Hear This Tip for Newborn Audio Screenings
Question: What is the appropriate code to use for conducting hearing screenings on newborns or infants? [...]

Podiatry Coding:
Consider These ICD-10-CM and CPT® Tips When Coding Ankle Fracture Repairs
Learn how to identify fractures and treatment from the documentation. Podiatrists frequently treat ankle fractures, [...]

Ob-Gyn Coding:
Know When to Report a Hysteroscopy Code
Question: I’m not sure what codes to assign for the procedure listed below because a [...]

Compliance:
Lean on Due Legal Process to Comply With HIPAA
Question: Should our medical practice be asking patients about their citizenship or immigration status? New [...]

General Coding:
Modifier 63 Can Be Redundant
Question: Why can’t I append modifier 63 to CPT® code 36450? The patient in question [...]

Practice Management:
Consider Adjusting Portal to Accept Summer Camp Forms
Question: Spring can be stressful for our office, in part because we are suddenly inundated [...]

Technology & Innovation in Healthcare:
Review AI Laws if Your AI Chatbot Engages With California Users
Question: Our healthcare organization deployed an artificial intelligence (AI) chatbot recently, so patients can relay [...]

Neurosurgery Coding:
Close Gaps in Your Burr Hole Surgery Coding Knowledge
Know how clinical indications lead to proper code choice. When a patient suffers from a [...]

E/M Coding:
Use This Documentation Trick for Independent Historian
Question: Our specialty practice sometimes sees pediatric patients, and often a parent/guardian provides a lot [...]

Pediatric Coding:
Take the Pain Out of Migraine Coding
SDOH could significantly impact the reason behind a child’s migraine episodes. According to the

Orthopedic Coding:
Look to These Codes When Dealing with JIA
Question: The practitioner’s notes indicate that a patient is suffering from juvenile idiopathic arthritis (JIA) of [...]

Ob-Gyn Coding:
Use These 5 Tips to Fix Your Uterine Fibroid Coding Mistakes — Before They Happen
Here’s how to distinguish fibroids from polyps. When you’re coding procedures related to uterine fibroids, [...]

Medicare Regulations:
Prepare for Implementation of Key TEAM Components and Waivers for Telehealth
Ensure staff know about the details, participation, and payment requirements for telehealth services under TEAM. [...]

Neurology & Pain Management Coding:
Do This When Coding for Sacroiliac Joint Tests
Question: An established 62-year-old patient presents with a seven-month history of chronic, dull, aching low [...]

Cardiology Coding:
Consider Peripartum Status When Coding Cardiomyopathy
Question: A patient was referred to a cardiologist after having shortness of breath. The patient [...]

Oncology/Hematology Coding:
Understand This MUE and How to Override It
Question: Our provider ordered 180 mg of lanreotide on the same date of service (DOS) [...]

Gastroenterology Coding:
Understand Why Gastroenteritis Coding May Not Be So Straightforward
Here’s why viral versus bacterial matters. As a medical coder, you know that every line [...]

Diagnostic Radiology Coding:
Code Head, Brain, and Neck CT Scans With This Detailed Guide – Part 2
Learn how to report 3D rendering. CT scans are a versatile imaging technique that uses [...]

Primary Care Coding:
Clear up Concussion Coding Confusion
There are a few important questions to consider when coding for this condition. Concussions are [...]

Cardiology Coding:
Here’s What You Need to Know About Heart Failure Coding
Get into the nitty-gritty documentation to find the correct HF code to report. Heart failure [...]

Gastroenterology Coding:
How Do I Report a Family History of Colon Polyps?
Question: Hi, I’m a medical coder at a busy gastroenterology practice, and I need some [...]

Path/Lab Coding:
Get the Most for Your Pathology Consultation Work
Decide if you want to reward time or toil. When your pathologist performs a pathology [...]

Ob-Gyn Coding:
How Should I Code Botox Injections Into Pelvic Floor Muscles?
Question: Hi, I’m working in an ob-gyn practice, and we recently had a patient receive [...]

View All

Subscribe to newsletter