Wiki Help with fracture coding

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dedramerritt

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I have not done any fracture coding.
I have an order and the diagnosis on the order is R grade 3 open tibia fracture with segmental fibular fracture.
I do not have a clue where to start coding this. Can someone please help me.
Thanks
 
24500 billable with E/M or not

Assessment
1. Proximal humerus fracture (S42.209A)

Plan
Proximal humerus fracture
1. Start: Oxycodone-Acetaminophen 5-325 MG Oral Tablet; 1-2 tabs every 4-6 hours as
needed for pain. Do not exceed 8 tabs in 24 hours
2. Ref to Physical Therapy Out / Ancillary - PreCert For: Proximal humerus fracture
early gental ROM after fracture
modalities as indicated Status: Active - Perform Order Requested for: 31Dec2018
(MU) Care Summary provided. : Yes
Referral Status (For CCR/Benefits Use): : Pending
Evaulate Only? Eval and Treat? Please provide details: : eval and treat
Body Site/Location(s) to be treated? (L/R/BL - Upper/Lower - etc) : upper
Patient Take Home Info:
Patient with minimally displaced right proximal humerus fracture. I discussed with patient about conservative measures to include a sling for the 1st 2 weeks. Patient is to start physical therapy for early gentle range of motion and progression to strengthening. Follow-up will be in 2 weeks to ensure no further displacement of the fracture.

Patient was reassured that there is no dislocation


All patients should ensure an adequate intake of dietary calcium (1,200 mg per day) and Vitamin D (1,000-2,000 IU per day) unless otherwise contraindicated.

Discussion/Summary
Medications were reviewed and reconciled. Allergies were reviewed and reconciled.
Speech recognition software was used to produce this record or report. Although the record was proofread, there might remain nonsensical verbiage. If this appears to have happened please bring this to our attention. Thank you.

Results/Data
Results Review- Ortho:
Recent films pertinent to today's visit were reviewed.
I personally reviewed and interpreted: Review of right shoulder x-rays from outside source show minimally displaced proximal humerus fracture without dislocation.

Chief Complaint
Chief Complaint*:
51 year female presents for right humerus fx
Date of injury: 12/23/18
Date of Encounter: 12/31/2018




History of Present Illness
HPI- Ortho:
51 year female presents for right humerus fx
Date of injury: 12/23/18
pt fell getting out of bathtub
pt has been in sling since 12/26/18
Current pain level 7/10 pt has been taking Oxycodone which does help somewhat

Pt went to the ER in Tennessee.
 
My understanding is that this is the first time your provider is seeing the patient (12/31). I'm assuming the patient had the sling placed by the Tennessee provider on 12/26. I don't feel that CPT 24500 is billable as your provider really didn't perform any type of closed treatment of the humeral fracture. The patient was already in the sling and your provider just basically told the patient to keep using the sling. I would only bill for the E/M code.
 
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