tci ED Coding & Reimbursement Alert - 2005 Issue 4

Reader Questions: When 'Possible,' Code Complaint

Question: A patient presented to the ED with the chief complaint of arm pain. The physician's final diagnosis is "possible supracondylar fracture." The doctor splinted the patient and referred him to an orthopedist for follow-up. The HPI notes a fall from a ladder that evening. The PE notes arm pain post fall, but nowhere in the dictation does it state "injury," "contusion," or "sprain." Should I report a code for injury, contusion, or sprain, or go with "arm pain" as the presenting complaint?Maryland Subscriber Answer: Because the fracture description includes the word "possible,"...

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