Fracture Documentation Inquiry

Fracture Documentation Inquiry

February 1, 2024

Recently a surgeon of ours documented the following for a patient evaluated in our office.

HPI: Right lateral depressed tibial plateau fracture

X- rays: Review of CT and X-Ray shows, “lateral split depressed right tibial plateau fracture with 8mm of lateral joint line depression.”

Diagnosis: Closed fracture of right tibial plateau, initial encounter

Plan: ORIF of tibial shaft fracture noting the joint instability

The coding staff assigned a level 3 encounter to this, and the surgeon is questioning why a displaced fracture requiring surgery would be considered low versus moderate risk for the problem addressed. The surgeon submitted a level four encounter and the staff down coded to a level three. Are you able to comment?

Thank you for sending this via our ongoing consulting agreement and agreeing to use this as a coding coach.

  • Our first answer is to remind the providers, when possible, to address the complexity (risk) of the problem.
  • Second, the staff should query the provider if they do not understand the type of fracture and associated risk.
  • Third, the surgeon gave a diagnosis of a closed fracture of the right tibial plateau, initial encounter.

When speaking with the physician, a recommendation to document the diagnosis as “displaced fracture of lateral condyle of right tibia, initial encounter for closed fracture, initial encounter” to better describe the fracture that occurred.

The AMA has defined the Problems Addressed that would be pertinent to this condition as

  1. Acute uncomplicated injury
  2. Acute complicated injury with risk of complications, morbidity, or mortality.

Work with the surgeon to best determine the risk associated with the fracture. This is a great example of where enhanced documentation and speaking with the surgeon has benefits for both.

Additionally, the surgeon stated he reviewed the CT and XR and documented the findings. Remember to remind the surgeon of the difference between reviewing X-Rays and performing an independent interpretation—they are different and impact the level of risk in the MDM table.


*This response is based on the best information available as of 2/1/24.




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