I have a resident who is on hospice services. She apparently told the doctor that she fell, but not the nurses!! No one saw it. She is c/o of rib pain. There was no xray done r/t hospice. The doctor wrote in his progress note "pain.... consistant with rib fracture". and "acute rib fracture". Do I code these or not????? General opinion here is not to code it without the supporting xrays, but wanted other opinions .
Thanks!
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