99212 OR 99213 follow up fracture care

[cwilson3333]

Would like to have this office visit "audited" by another coder on the e/m visit code.
CC: Left Elbow Fracture
DOI 10-14-2019

HPI: X-rays performed in house
No complaints. He is here with his father

MEDICAL HISTORY: Denies

MEDICATIONS; None

ALLERGIES; NKDA

VITALS [ALL ARE DOCUMENTED IN THIS CHART.... I DID NOT LIST THEM HERE FOR THIS REVIEW]

EXAMINATION: MUSCULOSKETAL: On exam, he extends his elbow to 10 degrees and flexion to 120. Pronation 60 and Supination 35. Patient is nontender to palpation.
IMAGING; X-rays show good fracture callus

ASSESSMENT: Closed displaced fracture of head of left radius, with routine healing, subsequent encounter
Other Orthopedic Aftercare

PLAN: He can stop the sling at home. and avoid any contact or risk of falling. See in 2 weeks for repeat X-ray.

99212 or 99213 ???
73080
Dx: S52.122D
Z47.89

 

[mitchellde]

This is global to the fracture care so you would bill the 99024, if it was not billed as fx care then I would say 99212. For the diagnosis code only the S52.122D, the Z47.89 has an excludes 1 exclusion for all trauma codes.

 

[cwilson3333]

Thank you Debra
I would code the 99212 also. The doctors are looking for level 3 coding, so just checking my coding.