Wiki Suspected Fracture

[sorcha48]

I have a provider that used a dx of fracture when the fracture had not been verified as of the day that the visit occured. An x-ray was done and stated no fracture.

I explained that you could not use fracture unless it had been confirmed.

She stated it was "in her opinion" a fracture which was confirmed 2 days later during a CT scan.

She entered in her notes 3 days after the visit.

What should be coded? For the encounter.

 

[mitchellde]

What did the documentation state for the encounter before the CT scan amendment? If it was a possible or rule out dx then you cannot code it. If the note stated it was a fracture, then you code it.

 

[sorcha48]

suspected fracture

The note indicated rib pain from a fall.

 

[sorcha48]

suspected fracture

Would the provider be able to argue that she can have fracture since it was later confirmed?

I say no, but is she right?

 

[mitchellde]

no you cannot go back in time and change what is a symptom to a fx based on future confirmation, so you code the rib pain and the E code for the fall.

 

[boozaarn]

?

E code with symptoms?
I think it needs to be codded as 786.50 and v15.88

 

[mitchellde]

Of course you can use an E code with symptoms. This is a patient that fell and has an injury an injury does not have to be a fx or a laceration it can be just pain. The V15.88 is for a patient that has fallen in the past and is at risk for falling again. It is not appropriate for this encounter.