cwilson3333
Expert
Need to double check coding on the new patient visit:
CC: Clavicle Fracture
HPI: the patient is a 7 year-old who injured his right shoulder on 10-13-2012. The patient fell and went to the ER. He is now in a sling for the fracture. He looks fairly comfortable.
No prior orthopaedic problems.
ROS: Review of systems is in the patient's chart and has been reviewed.
PE: WDWN male. Right shoulder: He has mild swelling in the mid third of the right clavicle. He is mildly tender. NVI.
X-rays: Taken at Hospital show a mid third clavicle fracture with displacement.
A: Right Clavicle Fracture, acceptable alignment.
P: Sling. He will f/up in three weeks for an X-ray. It will take 4-6 weeks for complete healing.
Electronically signed by doctor
Am I looking at CPT 99203 or /CPT 99204. I do not know how the ER Doc coded his vist, i.e. fracture care. Since patient was seen first at ER, I do not think I can code for fracture care, even though my doctor will be doing the global care.
Need some imput from any of you ortho coders.
Thanks,
CW
CC: Clavicle Fracture
HPI: the patient is a 7 year-old who injured his right shoulder on 10-13-2012. The patient fell and went to the ER. He is now in a sling for the fracture. He looks fairly comfortable.
No prior orthopaedic problems.
ROS: Review of systems is in the patient's chart and has been reviewed.
PE: WDWN male. Right shoulder: He has mild swelling in the mid third of the right clavicle. He is mildly tender. NVI.
X-rays: Taken at Hospital show a mid third clavicle fracture with displacement.
A: Right Clavicle Fracture, acceptable alignment.
P: Sling. He will f/up in three weeks for an X-ray. It will take 4-6 weeks for complete healing.
Electronically signed by doctor
Am I looking at CPT 99203 or /CPT 99204. I do not know how the ER Doc coded his vist, i.e. fracture care. Since patient was seen first at ER, I do not think I can code for fracture care, even though my doctor will be doing the global care.
Need some imput from any of you ortho coders.
Thanks,
CW