tci ED Coding & Reimbursement Alert - 2024 Issue Q2

You Be the Coder: Fracture by Assault

Question: Encounter notes indicate that a patient reported to the ED after someone assaulted them with a rolling pin. Upon exam, the ED physician notes bruising and swelling on the left forearm. The physician orders X-rays, which reveal a pathological fracture of the left radius. After reviewing the X-rays, the physician performs closed treatment of the fracture without manipulation. Encounter notes indicate that during the evaluation and management (E/M) portion of the service, the physician performed moderate-level medical decision making (MDM). How should I report this encounter? Iowa Subscriber Answer: For this claim, you should report: 25500 (Closed treatment...

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