tci ED Coding & Reimbursement Alert - 2012 Issue 10

Don't Fall Apart Over E/M With Fracture Care

Question: Consider the following Chart documentation:A nine year-old patient comes in with a history of having fallen off the playground equipment at school. There is an area of tenderness on the distal forearm. Below are some elements of the chart documentation:PFSH- lives with parents, no medical problems,ROS - all negativePE, general exam: vs. normal, HEENT: Nml, CHEST -CTAB, ABD - nmlExtremity- tender area of swelling just proximal to wrist. ROM of wrist is limited by pain, sensory intact to light touch. cap refill <2sec.X-Ray is ordered-X-Ray reading by the ED attending: Torus fracture of distal radius...

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