For Risk Adjustment, have you encountered guidance to pick up the osteoporosis that is listed in the 'problem list/past medical history' if in the current encounter the patient comes in for a femur fracture due to fall?
For example, patient presents to ER due to fall. X-ray confirms there is a femur fracture. The provider documents how the patient slipped/fell out of bed. In the 'problem list/past medical history' it has a listing of a previous osteoporotic fracture dx code or just lists osteoporosis.
I've been given guidance that since osteoporosis is listed in the problem list, I can automatically assume and code the current fall fracture as a osteoporotic fracture, not a traumatic fracture. The provider never mentioned anywhere else in the ER note that the patient has osteoporosis.
Would you/do you pick up osteoporosis this way for fractures? I've tried to research this particular scenario, but haven't been able to find anything.
Your guidance would be very helpful. Also, I cannot query the provider to get clarification.
For example, patient presents to ER due to fall. X-ray confirms there is a femur fracture. The provider documents how the patient slipped/fell out of bed. In the 'problem list/past medical history' it has a listing of a previous osteoporotic fracture dx code or just lists osteoporosis.
I've been given guidance that since osteoporosis is listed in the problem list, I can automatically assume and code the current fall fracture as a osteoporotic fracture, not a traumatic fracture. The provider never mentioned anywhere else in the ER note that the patient has osteoporosis.
Would you/do you pick up osteoporosis this way for fractures? I've tried to research this particular scenario, but haven't been able to find anything.
Your guidance would be very helpful. Also, I cannot query the provider to get clarification.