Wiki no fracture vs "healed" fracture

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cjhalk@yahoo.com

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I'm not confident on my diagnosis for this patient. Patient states he fractured his distal ulnar in Nov 2013. Patient is not being seen for any pain related to the fracture and the CC is "follow up."

The provider did a musculoskeletal exam and found no pain, no swelling, and no palpitation.

Provider diagnosed the patient with a fracture of radius/ulna. He ordered x-rays (and in my opinion here is the kicker) "will order x-rays to document." But no treatment was issued.

Im not going to code the fracture - there is no fracture according to the documentation. At best, there is a healed fracture. But there is also no pain, and no reason the patient came to the office.

So would I just do the follow up V code?

V67.4 Follow up exam following treatment of healed fracture (although notes do not say healed fracture)
Or
V67.9 Unspecified follow up exam.

Thoughts?

Thank you.
 
Hi Chris,
If you have access to ICD-9-CM look up on Chapter 17: Injury and Poisoning >> subsection (B). Coding of Traumatic Fractures. According to ICD-9-CM Guidelines..... Fractures are coded using the aftercare codes(Subcategories V54-0, V54.1, 54.8, or 54.9). I personally think is 54.12 - Aftercare for healing traumatic fracture of lower arm. Hopefully this information will help.

Janie Reyes CPC-A
Coder
Consultants Pain Mgmt.
Secretary SA Local Chapter
 
I agree with the follow up not the aftercare code. If the patient had a fx in Nov of 2013 with no further complaints then this fx has healed and the patient is in the office for a follow up. The difference between aftercare and follow up is that aftercare is considered more of a hands on visit for things like dressing changes, whereas the follow up is a surveillance of the patient, that is what this visit sounds like to me. I guess the question is why is the patient in the office, is it a routine 6 month follow up? the timing is correct for that, so use the V67 code for follow up.
 
Hi,
It sounds V67.4 would be more appropriate since V67.4 represents HEALED fracture scenario. The fracture occured around 6 months before without subsequent pain or any complication. It sounds that fracture had healed. In contrast V54.12 represents aftercare of HEALING fracture.

So my suggestion would be V67.4
 
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