Wiki Fracture and Injury Coding

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tvisocchi

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Hi,

I work for a Mental hospital. There are many instances when the patient might currently have an injury or fracture that they are not treated for at the hospital but, the Dr. will list it as one of the Pt's diagnosis. What is the proper way to code for the injury/fracture if the pt is not being treated for it but, it is just a current issue. I wasn't sure if the V-code (history of injury or history of fracture) is used since, these codes are used when the injury/fracture is healed. Please help:)

Thank you

Tanya
 
If you are coding for the physician services, the ICD guidelines state, "list additional codes that describe any coexisting conditions," and "code all documented conditions that coexist at the time of the encounter/visit or affect patient care treatment or management."

If you are coding for the facility, UHDDS suggests, "all conditions that coexist at the time of admission, that develop subsequently or that affect the treatment received and/or the length of stay" should be coded. Those diagnoses that impact the following require:
* Clinical Evaluation
* Therapeutic treatment
* Diagnostic procedure
* Extended LOS
* Increased nursing care/monitoring.

The coding of traumatic fractures guidelines indicate the coder should assign an acture fracture code "while the patient is receiving active treatment for the fracture."

Hope this helps.
 
Hi Kevin,

My question is, how are fractures/injuries coded if the patient is not receiving treatment for them? Since the hospital is a Psychiatric hospital, the patient is not coming for any medical treatment but, the patient may have a fracture or injury that is not affecting the treatment of the patient.

Thank you so much,

Tanya
 
I believe he is saying to use the code for the type of fracture it actually is if it is a current injury. If not current then use the V code.
 
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