Wiki documentation requirements for splinting and fracture care

[jaciwismar]

Hi all,
I'm looking for a resource that states what the provider is required to document in his procedure note in order to bill for splinting in the Emergency Department? For example; type of splint, correct placement of splint, post placement neurovascular check.

Are those same items also required to be in the procedure note if it is definitive care and I"m coding fracture care. For example, if the provider gives definitive care for a finger fracture by splinting it and giving pain control, is he required to document the type of splint, correct placement of splint, post placement neuro check, etc?

Thank you!
Jaci

 

[Suriya Narayanan]

Coding Splint is Depends upon Payer .
If Payer is Federal , then Splint should be done by Emergency Room MD/PA/MLP/NP .
If Payer is Commercial , then Splint can be coded when there is post placement NV Exam (Like N/V Intact ,Capillary refill) by Emergency Room MD/PA/MLP/NP.

In Case of Fracture care , Its mandatory to document Imaging Evaluation , Definitive Treatment and Follow Up referral by physician to code Fracture care.
Imaging Evaluation may be X-ray/CT/MRI .
Definitive care includes Splint/Strap/Sling/Ice application and Pain Medication .
Follow Up referral should not be to Orthopedic/Specialist with in 3 days from DOS by ER MD.