Wiki Documentation for Fracture treatment and cast applications

[dawnefd@comcast.net]

Hello, I am looking for information re: how a physician should document fracture treatment of closed fracture and cast applications.
I am finding a lot of information re: CPT coding but not actual chart documentation information.
Can anyone point me in the right direction?
I prefer Blue Cross guidelines but will appreciate any official guidelines. CMS if Blue Cross is not available.
thank you

 

[Orthocoderpgu]

First of all the cast is part of the initial fracture care. When it's replaced the physician should document the type "long arm cast".

For fracture care the physician must document that they are either "initiating fracture care" or "will follow the facture non-operatively". This must be in the documentation somehow. This just cannot be "assumed", even if you have a billing sheet with it marked. That is not the legal documentation for the service.