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I'd appreciate feedback on how to code when a doctor states he thinks patient has what he termed a 'clinical fracture' and the subsequent xray result shows no fracture. Thanks in advance for any help.
It is not uncommon for diagnostic study to contradict or not support a physician's clinical decision. If the physician makes a clinical diagnosis and decides to render treatment, you are to code that condition and not question the physician's medical decision making.
I would speak to the provider to better understand what clinical indications led to the clinical diagnosis before assigning a sign/symptom code.
Based solely on what is in this thread, I would have to disagree. Where's the documentation? Asking the doc to document his/her decision making is not the same thing as a coder "questioning" medical decision making. There has to be SOMETHING in the note to go by.
To use an admittedly outlandish example, what if the doc sees a patient 20 feet across the room, and says that that person has lung cancer and prescribes meds? Would we follow blindly along?
Once again, this assumes there is no documentation of any kind in the original note
The question was not regarding arbitrary selecting a diagnosis, rather the physician making a 'clinical' diagnosis. This is why it's referred to as 'clinical' diagnosis.
Since your question was specific to a fracture - this should be visible on x-ray so I would speak with your provider.
Not all fractures show up on x-ray in the first few days. It may be a hairline fracture that does not show calcification healing until later. http://www.aapsm.org/ct0398.html
reports: "In some cases, the signs of a stress fracture may not show up on an X ray for as long as four or five weeks or may never show up on a conventional X ray. Other forms of imaging, including bone scans, CT scans and MRIs, may detect a stress fracture that does not show up on conventional X rays."