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Good
point Bryan. Perhaps it would be best to code the actual symptoms presenting in
this case.
Interesting point, but if no x-ray is available,
then you can not code fracture. The MD does not have x-ray vision, so
unless we have supporting documentation I would not code fracture. Just
my thoughts. Have a good day!
bryan
----- Original Message -----
Sent: Tuesday, February 17, 2004 7:57
AM
Subject: RE: "consistent with"
diagnosis ???
It
is my understanding that when an MD is "ruling something out" you code for
what ever is being ruled out so I would code for the fracture especially
since the MD has it documented and it is affecting her current
status.
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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