Wiki Documentation - 24560

[KoBee]

Having trouble understanding if I am missing documentation or understanding the procedure definition correctly. I have a provider who is using CPT 24560 but I don't see a specific procedure note, shouldn't there be??


History of Present Illness: This is a　9 y.o.female　who present with　Right　Elbow pain after falling while riding roller skates.

No past medical history on file.
No past surgical history on file.
No current outpatient medications on file.
No family history on file.


No Known Allergies

Review of Systems

GENERAL: No unusual　weight gain/loss or fevers.
EYES: No recent changes.
EARS/NOSE/MOUTH/THROAT: No complaints.
RESPIRATORY: No shortness of breath, cough, hemoptysis, or wheezing.
CARDIAC: No chest pain, palpitations, tachyarrhythmias or edema.
GI: No abdominal pain　or change in bowel habits.
GU: No difficulty urinating.
MUSCULOSKELETAL: Denies all symptoms except for HPI.
NEUROLOGICAL: No seizures.
SKIN/CHEST WALL: No complaints.
PSYCHISTRIC: No recent significant change in mood or behavior.
ENDOCRINE: No significant change.
HEMATOLOGY/LYMPHATIC: No unusual　bleeding or clotting.
ALLERGIC/IMMUNOLOGIC: No additional allergic reactions or recurrent infection

Physical Exam

Skin　abrasion on elbow
ttp over olecranon
NTTP over lateral or medial elbow
Sensation intact to light touch　2/2　Radial, Ulnar, Median nerve distribution
Motor　5/5　Extensor pollicus Longus, Flexor pollucis longus, Dorsal interossei muscles, wrist extensors, wrist flexors

Imaging:
XRAY　right　Elbow: AP, Obliques, and lateral views: I do not appreciate a fracture

Assessment and Plan: This is a　9 y.o.female　with right　Elbow pain possible occult fracture
- LAC (long arm cast)
- Return to clinic in　4　weeks　xrays oop. If fx will recast. If no fx, no cast

 

[Orthocoderpgu]

I see two issues. This documentation does not support billing for fracture care (24560). According to this documentation the physician has not diagnosed a fracture. After they do diagnose a fracture and the physician wants to bill for fracture care, the documentation needs to show that decision being made. I have worked with my providers and they now state that they are "initiating fracture care". This needs to be documented. It can't be "implied". Remember your physician can bill either office visits or fracture care and it's their choice. But that choice must be documented. Any procedure must be supported in the medical record. Good news is that this is an easy fix. If the patient returns and a fracture is identified, your physician can initiate fracture care.