rjenn86
Guru
Wondering how others would code this? In regards to the OV and dx. Would you bill out with V54.09 and just do OV with mod. 25...Or Does modifier 55 need to be used on the ov? I'm unsure of how to bill this out, since pt is only wanting to do post op care with us. Thank you!!
Patient March 14, 2014. Pt was climbing a chimney. Pt was coming down approximate 5 feet out of a protective foot wear landed and sustained a distal comminuted tib-fib fracture. This occurred and then pt was treated at another hosptial with intramedullary rod and fibular plate. Patient's from this area and has opted to have postop care performed here.
PHYSICAL EXAMINATION:
Examination shows left lower extremity skin is intact some drainage from left lateral incisions noted. Patient has an area of blistering and some necrotic appearance to the tissue. Patient shows typical swelling is negative for pain in the calf musculature and foot goes to neutral position.
X-RAY EXAMINATION
Inside X-Rays 2 views left tibia and fibula demonstrate comminuted distal tibia fracture with intramedullary rod with 3 screw fixation, distal acceptable alignment was noted on AP and lateral view. Patient's fibula shows plate and screws. No problems alignment. No evidence of callus formation.
ASSESSMENT:
Assessment left distal tib-fib fracture status post intramedullary rod, open reduction internal fixation recommendations. Patient's replacing the splint to come back in a week using kirsch keep the leg elevated diminished edema on the schedule. If it doesn't have constant pressure try to push incision apart. In a week if incision is without drainage or loose sutures were placed in a short-leg cast.
Patient March 14, 2014. Pt was climbing a chimney. Pt was coming down approximate 5 feet out of a protective foot wear landed and sustained a distal comminuted tib-fib fracture. This occurred and then pt was treated at another hosptial with intramedullary rod and fibular plate. Patient's from this area and has opted to have postop care performed here.
PHYSICAL EXAMINATION:
Examination shows left lower extremity skin is intact some drainage from left lateral incisions noted. Patient has an area of blistering and some necrotic appearance to the tissue. Patient shows typical swelling is negative for pain in the calf musculature and foot goes to neutral position.
X-RAY EXAMINATION
Inside X-Rays 2 views left tibia and fibula demonstrate comminuted distal tibia fracture with intramedullary rod with 3 screw fixation, distal acceptable alignment was noted on AP and lateral view. Patient's fibula shows plate and screws. No problems alignment. No evidence of callus formation.
ASSESSMENT:
Assessment left distal tib-fib fracture status post intramedullary rod, open reduction internal fixation recommendations. Patient's replacing the splint to come back in a week using kirsch keep the leg elevated diminished edema on the schedule. If it doesn't have constant pressure try to push incision apart. In a week if incision is without drainage or loose sutures were placed in a short-leg cast.
