Wiki diagnosis question - History states that the patient

[fisherdawnmarie]

History states that the patient had an injury several months ago.

The impression indicates an osteochondral fracture of the lateral femoral condyle with significant subchondral cystic degeneration and marrow hyperemia.

Would you use 821.21 for this type of fracture?

Thank you.

 

[dmaec]

fisherd - I like 821.21 for this also. Appears the patient has this fracture at present time, as being seen by the physician. It doesn't say the patient had a fracture months ago. It states they were seen for an "injury" months ago, and the impression "now" is the fracture.
(we don't use Ecodes at our clinic)

 

[Lisa Bledsoe]

History states that the patient had an injury several months ago.

The impression indicates an osteochondral fracture of the lateral femoral condyle with significant subchondral cystic degeneration and marrow hyperemia.

Would you use 821.21 for this type of fracture?

Thank you.

Is the "injury" from several months ago this particular fracture? Is it possible that this is a mal-union or non-union fracture (733.81 - 733.82)?

 

[smwermter]

I think that if the patient has not been seen previously for the fracture then using the 821.21 would be correct.

 

[jayanthi]

Hi
since the fracture is not coded for the present condition of the injuries occured for the several months ago, we can go head by coding 821.21.
If fracture has mentioned before itself and the present condition states that the patients has still fracture means, we can select the code from the late effect list (i.e E929.0 - 929.9)