Wiki ED fracture

[dkhclement]

Pt was seen in the ED and dx with tibial plateau fx. ED physician did not specify tibial plateau fx, merely stated fracture of the tibia. Radiology report (read by radiologist who is a doctor) gave more specificity as to the fracture so isn't it OK to code the higher degree of the fracture when available in the x-ray report?

Also, in another case, the ED MD wanted to discuss with the radiologist his fracture findings. Something in there that he maybe disagreed with. If the x-ray definitely says fracture, we could code the fracture, right, and not just arm pain? Sorry, this goes to an in-house work discussion that we are currently having regarding coding only the arm pain and not the fracture even though the x-ray says fracture in this case.

Thanks for your input.

 

[mitchellde]

Since the radiologist is a physician you are allowed to use the radiology report for diagnosis information.

 

[dkhclement]

that's why i do it

Yes, that is why I go to the x-ray and code the fracture to the highest specificity. Thanks for the confirmation. I don't think I could ever just code arm pain when the x-ray clearly states that there is a fracture.