Wiki Vertebral compression fractures

[buckeye56]

ED coding, an elderly woman has a fall and one of the diagnoses is a vertebral compression fracture. Another diagnosis is back pain. The record does not specify whether or not this fracture relates to the fall or if it is traumatic or pathologic (x-ray report says that this is unknown). When I code, should I assume that it is traumatic or pathologic?

 

[harshila]

hi i code radiology my guss is 733.13

 

[jdrueppel]

If the diagnosis is within E&M documentation of a trauma (i.e. the fall) I would code it as traumatic. This at least gives the payer the opportunity to investigate for third party liability.

Julie, CPC

 

[buckeye56]

Thanks

Thanks for the replies. When I had a chance to discuss it with my supervisor she said she would code it as traumatic, since there was a fall.

 

[cinnamon]

ED coding, an elderly woman has a fall and one of the diagnoses is a vertebral compression fracture. Another diagnosis is back pain. The record does not specify whether or not this fracture relates to the fall or if it is traumatic or pathologic (x-ray report says that this is unknown). When I code, should I assume that it is traumatic or pathologic?

You don't code the back pain since you have the DX of vertebral compression fracture, possibly cause the back pain. Also Query the physician to find out how the fracture cause and whether traumatic or pathologic. Don't code just code anything. The physician would know and can give more details to help with the info in order for you to code properly.