Karen Posted Tue 13th of October, 2015 12:00:47 PM
Patient comes into office & first time ever seen by our MD, the patient had a injury several months ago but didn't seek any treatment. The diagnosis is routine healing of closed, nondisplaced lateral malleolous. So how would you code this since initial encounter by a new physician but is routine healing?
SuperCoder Answered Wed 14th of October, 2015 02:28:22 AM
"Thanks for you question.
We cannot code this scenario as an initial encounter because the physician is not providing active treatment. if the patient is getting active treatment by a new provider then only considered it as an initial encounter. But here the diagnosis is routine healing of closed, nondisplaced lateral malleolous, so we will code this as a "Subsequent encounter for fracture with routine healing."
Hope this will help you."