tci Outpatient Facility Coding Alert - 2018 Issue 6

Reader Question: Assign Fracture Dx to Relevant Surgical Code, Only

Question: We have a patient who underwent an open reduction and internal fixation (ORIF) for a left, displaced lateral malleolus fracture in addition to an ORIF for left proximal fibular fracture. Should I include both diagnosis codes on both procedures? Minnesota Subscriber Answer: In your example, you should not designate both diagnosis codes to both procedures, despite the fact that the fractures are within close proximity to one another. Just as you would if the provider performs the procedures on entirely separate anatomic sites (i.e. left leg, right leg), you will only apply the diagnosis relevant to each...

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