Bonnie Posted Wed 16th of October, 2019 10:32:15 AM
I have a coding question regarding coding for fracture initial; routine healing? Our concern is that the provider notes "slight further compression deformity" indicating that the condition has worsened. Documentation: A 77-year-old male who continues to recover from a T12 compression fracture. Upright x-rays today in the brace show slight further compression deformity of the T12 fracture, but no significant kyphosis. He should continue to wear his Jewett hyperextension brace when he is out of bed and ambulatory for another 6 weeks. He will follow up with me at that time with flexion and extension x-rays.
SuperCoder Answered Thu 17th of October, 2019 04:29:14 AM
Thanks for your question.
Since a slight further compression deformity is still present, which indicates that the condition has worsened, this cannot be considered as routine healing. Instead, this may be considered as delayed healing. So, the following code may be reported in this case:
S22.080G-Wedge compression fracture of T11-T12 vertebra, subsequent encounter for fracture with delayed healing
Please correlate this with the documentation in the medical record.
Please feel free to write if you have any question.