Having some trouble understanding when Orthopedic can bill for fracture care or not. Maybe someone can help me understand what to look for and what is billable or not. help :/ Patient was seen in urgent care and splint was applied and orthopedic wants patient to return in 4 weeks.
This orthopedic wants to bill
29075 (application)
25630 (fracture)
99243 (E/M)
Patient seen at the request of Dr. xxxxx
Wrist Injury
The incident occurred 3 to 5 days ago. The pain is present in the right wrist. The quality of the pain is described as aching. The pain does not radiate. The pain is mild. The pain has been improving since the incident. Pertinent negatives include no chest pain or tingling. The symptoms are aggravated by movement and palpation. He has tried NSAIDs, rest, immobilization and ice for the symptoms. The treatment provided mild relief.
Patient fell while riding his dirtbike, injured his right wrist. Seen in urgent care, placed in a splint. Here for evaluation. Denies any other injuries.
There is no problem list on file for this patient.
No past medical history on file.
No past surgical history on file
No Known Allergies
Review of Systems
Constitutional: Negative for chills and fever.
Respiratory: Negative for cough and shortness of breath.
Cardiovascular: Negative for chest pain.
Gastrointestinal: Negative for abdominal pain, constipation, diarrhea, nausea and vomiting.
Genitourinary: Negative for dysuria, frequency and urgency
Musculoskeletal: Positive for joint pain.
Neurological: Negative for tingling.
Patient's medications, allergies, past medical, surgical, social and family histories were reviewed and updated as appropriate.
Physical Exam
Constitutional:
General: He is not in acute distress.
Appearance: Normal appearance.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Pulses: Normal pulses.
Pulmonary:
Effort: Pulmonary effort is normal.
Abdominal:
General: Abdomen is flat.
Musculoskeletal:
Right wrist: He exhibits decreased range of motion (mild, due to pain), bony tenderness (no TTP distal radius or ulna, mild snuffbox tenderness) and swelling (mild). He exhibits no deformity.
Comments: Able to give thumbs up ok sign cross fingers
Neurological:
Mental Status: He is alert and oriented to person, place, and time.
Sensory: No sensory deficit.
Gait: Gait normal.
XRAY right hand:
FINDINGS:
No soft tissue mass is seen.
No definite tumor like lytic or blastic changes are seen.
IMPRESSION:
There is a likely nondisplaced distal scaphoid fracture. Consider follow-up 3 view wrist x-ray and navicular view in 7-10 days
Xray shows a possible nondisplaced scaphoid fracture. Given his tenderness will manage as fracture.
Advised of risk of nonunion with scaphoid fractures.
Placed in a thumb spica cast
Cast care instructions given
Follow up 4 weeks with xrays out of
This orthopedic wants to bill
29075 (application)
25630 (fracture)
99243 (E/M)
Chief Complaint | ||
Patient presents with | ||
• | Hand Problem | |
| | right hand injury |
Patient seen at the request of Dr. xxxxx
Wrist Injury
The incident occurred 3 to 5 days ago. The pain is present in the right wrist. The quality of the pain is described as aching. The pain does not radiate. The pain is mild. The pain has been improving since the incident. Pertinent negatives include no chest pain or tingling. The symptoms are aggravated by movement and palpation. He has tried NSAIDs, rest, immobilization and ice for the symptoms. The treatment provided mild relief.
Patient fell while riding his dirtbike, injured his right wrist. Seen in urgent care, placed in a splint. Here for evaluation. Denies any other injuries.
There is no problem list on file for this patient.
No past medical history on file.
No past surgical history on file
No current outpatient medications on file prior to visit. |
No current facility-administered medications on file prior to visit. |
Social History |
Tobacco Use | |||
• | Smoking status: | Never Smoker | |
• | Smokeless tobacco: | Never Used | |
Substance Use Topics | |||
• | Alcohol use: | Not Currently | |
| | Alcohol/week: | 1.0 standard drinks |
| | Types: | 1 Cans of beer per week |
| | Frequency: | Monthly or less |
• | Drug use: | Not Currently |
Constitutional: Negative for chills and fever.
Respiratory: Negative for cough and shortness of breath.
Cardiovascular: Negative for chest pain.
Gastrointestinal: Negative for abdominal pain, constipation, diarrhea, nausea and vomiting.
Genitourinary: Negative for dysuria, frequency and urgency
Musculoskeletal: Positive for joint pain.
Neurological: Negative for tingling.
Patient's medications, allergies, past medical, surgical, social and family histories were reviewed and updated as appropriate.
Objective: |
Physical Exam
Constitutional:
General: He is not in acute distress.
Appearance: Normal appearance.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Pulses: Normal pulses.
Pulmonary:
Effort: Pulmonary effort is normal.
Abdominal:
General: Abdomen is flat.
Musculoskeletal:
Right wrist: He exhibits decreased range of motion (mild, due to pain), bony tenderness (no TTP distal radius or ulna, mild snuffbox tenderness) and swelling (mild). He exhibits no deformity.
Comments: Able to give thumbs up ok sign cross fingers
Neurological:
Mental Status: He is alert and oriented to person, place, and time.
Sensory: No sensory deficit.
Gait: Gait normal.
XRAY right hand:
FINDINGS:
No soft tissue mass is seen.
No definite tumor like lytic or blastic changes are seen.
IMPRESSION:
There is a likely nondisplaced distal scaphoid fracture. Consider follow-up 3 view wrist x-ray and navicular view in 7-10 days
Assessment: |
1. | Right wrist pain | X-ray wrist right PA lateral and oblique |
2. | Nondisplaced fracture of distal pole of navicular (scaphoid) bone of right wrist, initial encounter for closed fracture | |
Plan: |
Advised of risk of nonunion with scaphoid fractures.
Placed in a thumb spica cast
Cast care instructions given
Follow up 4 weeks with xrays out of