Bernadette10
Guru
Clinic outpatient profee coding - I know we can code the more specific fracture diagnosis from an x-ray if the provider at least states a diagnosis of fracture in the assessment, but what if a subsequent encounter x-ray shows nondisplaced, but the original x-ray showed displaced? Which one should be coded? It looks to me like it was originally displaced, but as it healed it became nondisplaced.
DOS 11/8/22 The patient is post her 9/30/22 RT ankle fracture.
Exam: She is about 4 1/2 out of 5 posterior tib and peroneal testing today, normal extensor testing on the right.
11/8/22 X-ray RT ankle 3V - A healing, nondisplaced transverse fracture of the distal RT fibula is seen with residual soft tissue swelling noted laterally.
9/30/22 X-ray RT ankle 3V - An acute displaced transverse fracture through the RT distal fibula is seen with a 2 mm gap in the fracture line.
Assessment and Plan: RT ankle fracture. I would like to see her back in 3 weeks with an x-ray out of her brace. She is welcome to call or come in if she has any problems in the interim. She will begin physical therapy to get her strength and motion back.
Q&A: Coding fractures | ACDIS
5. Q&A: Coding fractures
Q: Please advise on the coding guidelines in ICD-10-CM regarding the coding of fractures and their specificity obtained from a radiology report. For example, a patient is diagnosed with ankle sprain but when radiology reads the x-ray it shows a fracture. Previous advice stated that we can code the fracture. Is this still valid for ICD-10-CM?
Can you also address if the following advice still applies: An outpatient encounter for pain with no site mentioned and an x-ray is done, and we are instructed to code pain of that site of the x-ray. Will the same advice be true in ICD-10-CM?
A: The AHA Coding Clinic 1st Quarter, 2013 answered this question by stating that the same advice would apply to more specific coding in ICD-10-CM.
A question sent to Coding Clinic asked about the specificity obtained from a radiology report and how it would be coded in ICD-10-CM. The question included examples regarding documentation of a sprain that the radiology report states is a fracture, and about site specificity, when the radiology report is more specific than the documentation in the medical record.
Coding Clinic answered the questions by stating that, “If the x-ray report provides additional information regarding the site for a condition that the provider has already diagnosed, it would be appropriate to assign a code to identify the specificity that is documented in the x-ray report.”
The same Coding Clinic also stated, “In the inpatient setting, abnormal findings are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provide whether the abnormal finding should be added.”
Advice from AHA Coding Clinic 1st Quarter, 2017 Outpatient Laboratory, Pathology and Radiology coding states, “For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, it is appropriate to code any confirmed or definitive diagnosis documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.”
DOS 11/8/22 The patient is post her 9/30/22 RT ankle fracture.
Exam: She is about 4 1/2 out of 5 posterior tib and peroneal testing today, normal extensor testing on the right.
11/8/22 X-ray RT ankle 3V - A healing, nondisplaced transverse fracture of the distal RT fibula is seen with residual soft tissue swelling noted laterally.
9/30/22 X-ray RT ankle 3V - An acute displaced transverse fracture through the RT distal fibula is seen with a 2 mm gap in the fracture line.
Assessment and Plan: RT ankle fracture. I would like to see her back in 3 weeks with an x-ray out of her brace. She is welcome to call or come in if she has any problems in the interim. She will begin physical therapy to get her strength and motion back.
Q&A: Coding fractures | ACDIS
5. Q&A: Coding fractures
Q: Please advise on the coding guidelines in ICD-10-CM regarding the coding of fractures and their specificity obtained from a radiology report. For example, a patient is diagnosed with ankle sprain but when radiology reads the x-ray it shows a fracture. Previous advice stated that we can code the fracture. Is this still valid for ICD-10-CM?
Can you also address if the following advice still applies: An outpatient encounter for pain with no site mentioned and an x-ray is done, and we are instructed to code pain of that site of the x-ray. Will the same advice be true in ICD-10-CM?
A: The AHA Coding Clinic 1st Quarter, 2013 answered this question by stating that the same advice would apply to more specific coding in ICD-10-CM.
A question sent to Coding Clinic asked about the specificity obtained from a radiology report and how it would be coded in ICD-10-CM. The question included examples regarding documentation of a sprain that the radiology report states is a fracture, and about site specificity, when the radiology report is more specific than the documentation in the medical record.
Coding Clinic answered the questions by stating that, “If the x-ray report provides additional information regarding the site for a condition that the provider has already diagnosed, it would be appropriate to assign a code to identify the specificity that is documented in the x-ray report.”
The same Coding Clinic also stated, “In the inpatient setting, abnormal findings are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provide whether the abnormal finding should be added.”
Advice from AHA Coding Clinic 1st Quarter, 2017 Outpatient Laboratory, Pathology and Radiology coding states, “For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, it is appropriate to code any confirmed or definitive diagnosis documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.”