tci ED Coding & Reimbursement Alert - 2006 Issue 1

Reader Questions: Consider Certainty for Fracture Dx

Question: When a patient presents with a fracture, we usually get an x-ray confirmation before we report the fracture diagnosis. If the x-ray comes back negative for the fracture, I ask the ED physician to amend her documentation so I can code to the highest degree of certainty. Do I need to keep this up, or can I make a final code decision about the fracture without a test confirmation?Tennessee Subscriber Answer: Your answer depends on the kind of fracture the patient has. Physicians can diagnose some fractures clinically, such as rib fractures, whereas other fractures--such as a...

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