Orthopedic Coding 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, our coder asks the 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?

Tennessee Subscriber

Answer: Physicians can diagnose some fractures clinically, such as rib fractures. With other fractures, such as a fracture of the scaphoid bone in the wrist, the physician must diagnose presumptively, which means that the diagnosis is based on mechanism and pain over the bone, and the practice must repeat x-rays at a later date to show the fracture. 

If, based on mechanism and exam, your orthopedist legitimately has the clinical impression that a bone is fractured, you should code the fracture diagnosis. If you are waiting for the confirmatory x-ray and you then know the patient did not suffer a fracture, you should not assign a fracture diagnosis code.

Remember, however, that you should never bill a "rule-out" diagnosis - if the physician orders an x-ray to rule out a scaphoid or other fracture, you should bill the diagnoses for the symptoms, or wait until you have a definitive diagnosis.