warrenfamily103@gmail.com
Networker
Hello everyone,
I am hoping for some input on coding fractures. I am trying to code a recent encounter and one of the diagnoses states left ankle fracture/ Dexa scan ordered. It does not state anything more specific. Looking in the chart, I can see that back in July, the patient called in stating he thinks he broke some bones in his ankle, but again, nothing specific about how it happened etc. Lastly, I reviewed the notes from the Orthopedic in July and it states that the patient was playing golf and felt a pain in his left ankle. he did not fall, just felt the pain after he hit the ball. I have always been somewhat confused because I have been told by some that a note stands alone so you can only code based on that note whereas others state to review the entire medical record. Please help! as it stands, what code would be best?
I am hoping for some input on coding fractures. I am trying to code a recent encounter and one of the diagnoses states left ankle fracture/ Dexa scan ordered. It does not state anything more specific. Looking in the chart, I can see that back in July, the patient called in stating he thinks he broke some bones in his ankle, but again, nothing specific about how it happened etc. Lastly, I reviewed the notes from the Orthopedic in July and it states that the patient was playing golf and felt a pain in his left ankle. he did not fall, just felt the pain after he hit the ball. I have always been somewhat confused because I have been told by some that a note stands alone so you can only code based on that note whereas others state to review the entire medical record. Please help! as it stands, what code would be best?