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Ask the Experts: Oct. 17, 2012

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Q: I am a student, and I am a confused on coding this question. A patient was able to make an appointment with the orthopedist within a few hours of being seen in the emergency department for a splint to his left wrist after a fall. The orthopedist reviewed the X-rays from the ED and agreed with the ED physician that the distal was fractured. A short arm fiberglass cast was applied. Report the CPT code for the closed treatment of this fracture. Could you please assist in coding this question? Do the ED visit, X-rays, splint, and E/M code need to be coded? I have chosen seven CPT codes, and I think I may be overthinking this question.

A: The question states to code the closed treatment of the fracture. As submitted, the E/M code for the office visit is not asked for. The orthopedist applied a short arm cast, which would be coded to CPT 29075 - Application, cast; short arm (elbow to finger) with the appropriate modifier -LT or -RT. It is common for students to overthink the questions they are given.  Always take a moment to be clear on what the question is asking for before beginning to code.
-Tina Lawrence, CPC, CPC-H, CCS

Q: I have just started as HIM coordinator at a long-term care nursing facility. We offer therapies and have an 18-bed acute wing, though rehab and "acute" patients are admitted throughout the building. Part of my responsibilities will be entering diagnosis codes into our system as well as doing MDS diagnoses. My new supervisor, who was doing my job for almost five years, had never heard of using a V57 code before and now I am confused about its use. We constantly have patients admitted for fractures, infections, wounds, etc. If the doctor orders PT and OT, is the therapy code used as the primary diagnosis? Please help. I have read the coding guidelines but maybe need to hear it put another way so I can understand. For example, I had two patients admitted. The transfer forms stated their reasons for admission were pneumonia and respiratory failure. Both had orders for PT and OT "eval and treat." What would be the primary diagnosis in these situations?

A: If these patient's are being admitted to an "acute" rehabilitation center, the question to ask is "what are they being admitted for?" While the patient may have had pneumonia and respiratory failure in the acute care facility, they should not be being admitted to a rehabilitation center for those acute conditions; they should be being admitted for the therapies that are needed due to the deconditioning/debility that was caused by those acute conditions. If the orders from the physician states OT, then V57.21 (encounter for Occupational therapy); if PT, then V57.1 (other physical therapy). If, however, they are being admitted for both OT and PT and/or ST, then V57.89 (other specified rehabilitation procedure - multiple training or therapy) will be used.  Please see Coding Clinic 3rd Q, 2006, pg. 3; Coding Clinic 4th Q, 2003, pg. 105-106; Coding Clinic 2nd Q, 2003, pg. 16; and Coding Clinic 4th Q, 2003, pg. 108-109. If the patient is still being treated for an acute condition, i.e. continued antibiotic for pneumonia or UTI, then it is appropriate to code those conditions as secondary diagnoses. *Note: This is used for the UB claim not the IRF-PAI assessment as these are two different instruments (Coding Clinic, 1st Q, 2002, pg. 18-19).
-Tasha Cameron, RHIA, CCS

Q: A patient presents to the emergency department and the MD orders a pt/ptt. The final diagnosis doesn't cover the test, but the patient is on Coumadin. The physician does not document Coumadin therapy in his notes or under medical history, but under allergies and medications he states see nursing MAR. Can the coder assign V58.61?

A: If the physician documents that he has reviewed and agrees with the nursing documentation, then codes may be assigned from the nursing documentation. See Coding Clinic 1st Q, 1999, pg. 13, Emergency Department Visit, "without being seen by physician, nursing documentation cannot be used for reporting codes."
-Christina Benjamin, MA, RHIA, CCS, CCS-P

ICD Q & A Archives

Kathleen, the following is the reply from Tina Lawrence regarding your question above: "The question does not state the orthopedist did any manipulation of the fracture or which bone is fractured. I could not determine a closed fracture treatment code with the information included. I could only provide the code as requested based on the information provided. If the original question as presented to the student included this additional information, then I would be happy to look at it again."

Lisa Brzezicki,  EditorOctober 17, 2012
King of Prussia, PA

Tina, why would you report only a cast application and not a closed fracture treatment for the orthopedist?

Kathleen October 17, 2012

Can cpt code 28190 be used for coding foreign body removal from the foot, removed without incision? Lay description of the code includes incision, but several consultants are telling us that incision isn't required.

Judith Doe,  Coder,  Bon SecoursOctober 17, 2012
Port Jervis, NY


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