Hi everyone,
How would you code a case where a 1 year old child came in the ER with a contusion of the forehead and fx of the humerus that occurred after the mother's boyfriend put the child down for a nap. The only documentation that refers to suspected abuse was the radiologist's report. The physician's report didn't mention abuse anywhere and no where in the documentation did it indicate that the authorities were notified. Would you code only for the contusion and fracture or would use of V71.81 be appropriate in this situation?
How would you code a case where a 1 year old child came in the ER with a contusion of the forehead and fx of the humerus that occurred after the mother's boyfriend put the child down for a nap. The only documentation that refers to suspected abuse was the radiologist's report. The physician's report didn't mention abuse anywhere and no where in the documentation did it indicate that the authorities were notified. Would you code only for the contusion and fracture or would use of V71.81 be appropriate in this situation?