cwilson3333
Expert
Would like to have opinion on the coding of this encounter for wrist fracture:
CC: Fracture wrist
HPI: The patient is an 11-year old left hand dominant male who injured his left wrist
on 8-15-13. He fell from off his skateboard.
No prior orthopaedic problems. He went to Urgent Care
PE: WDWN male. Left Wrist: Moderate Swelling. He is tender over the distal radius
and ulna. Elbow nontender. NVI; Skin intact. No obvious deformity.
XRAYS: Viewed on computer show a fracture of the distal radius and probably distal
ulna.
ASSESSMENT: Fracture of distal radius and ulna
PLAN: Short arm cast. F/u in a week for an Xray check. The cast will be in place for
4-6 weeks.
DR/transcriber
Date of Injury: 8-15-2013
Xrays performed: Urgent Care
The remaining EHR I won't list but is documented for Current medication, allergies, PSFH, and 3 vitals were taken.
99203-25
29075
ICD: 813.44
E885.2
[I bill itemized visits vs fracture treatment]
CC: Fracture wrist
HPI: The patient is an 11-year old left hand dominant male who injured his left wrist
on 8-15-13. He fell from off his skateboard.
No prior orthopaedic problems. He went to Urgent Care
PE: WDWN male. Left Wrist: Moderate Swelling. He is tender over the distal radius
and ulna. Elbow nontender. NVI; Skin intact. No obvious deformity.
XRAYS: Viewed on computer show a fracture of the distal radius and probably distal
ulna.
ASSESSMENT: Fracture of distal radius and ulna
PLAN: Short arm cast. F/u in a week for an Xray check. The cast will be in place for
4-6 weeks.
DR/transcriber
Date of Injury: 8-15-2013
Xrays performed: Urgent Care
The remaining EHR I won't list but is documented for Current medication, allergies, PSFH, and 3 vitals were taken.
99203-25
29075
ICD: 813.44
E885.2
[I bill itemized visits vs fracture treatment]