Wiki Coding Assumptions

[lburgos31]

So, I have an idea on what the answer is to this question, but I want to make sure I am not going crazy here.

If an orthopedic provider sees a patient at a trauma center (inpatient or outpatient), Lets say the patient has a clavicle fracture. Doc documents sling for comfort and non-op treatment. If the record does not state any manipulation was done, I should not be coding a fracture care code with manipulation. Basically, I should not assume manipulation was done.

Also, if the doc does not document any casting or bracing or manipulation done to a fracture I should not be coding fracture care at all correct?

 

[Orthocoderpgu]

Your first assumption is basically correct, your second is incorrect.

You should never bill for fracture care WITH manipulation unless the physician has documented this. The note will read very differently than without. The anesthetic should be documented, and that manipulation was performed and the fracture was reduced. Manipulation needs to be documented. You can never assume that it was done.

Casts, splints and so forth are included with fracture care. Does not matter if manipulation was performed or not. You would bill the ER visit and the fracture care codes.