Documentation Tip

Documentation Tip: Fracture / Trauma Care

Documentation Tip: Fracture/Trauma Care



There are numerous fracture and dislocation treatment codes.  Each code descriptor is specific to the anatomical location and treatment provided, i.e. which bone and was manipulation or reduction performed.

These codes include the appropriate diagnostic evaluation of that site of injury, manipulation or reduction, if applicable, treatment/stabilization modalities and the application of the first splint or other immobilization device.

Be sure to indicate in your documentation all of the following:

  • Conscious sedation if performed
  • Closed reduction if performed
  • What is used to immobilize
  • Surgical closure of any open wounds
  • Neurovascular check after splint application
  • Follow-up care instructions specifying the number of days the patient can wait for follow-up
  • Orthopedic consultation (whether immediate referral is required)

Proprietary Training for Clinical Understanding

In medicine today, there is a constellation of complaints, co-morbidities, patient history traits, treatment options, studies and interventions that practitioners must know about and consider. But, coders must also be fluent enough in this constellation to know which information is relevant, and which constitutes additional complexity.

And while coding “certification” by trade associations can a useful measure of a coder’s willingness to seek independent verification, it does nothing to assure that coders have the clinical tools they need to appreciate medical decision-making. In fact, the result of a non-clinician coder is often significant under-coding, a pervasive and relentless problem for most billing companies.

So, for our team of nurse coders throughout the country, Brault combines a proprietary certification program with frequent quality assessments and ongoing education on code definitions and reimbursement regulations.

Our coders are even trained to identify instances where critical care and observation care are being performed, but not adequately documented for billing purposes. By recognizing the clinical indicators that represent a “high probability of imminent or life threatening deterioration,” our coders can add extra value by prompting individual physicians to document time of attention (even days after the chart was presented for coding).

Proprietary Training for Clinical Understanding

In medicine today, there is a constellation of complaints, co-morbidities, patient history traits, treatment options, studies and interventions that practitioners must know about and consider. But, coders must also be fluent enough in this constellation to know which information is relevant, and which constitutes additional complexity.

And while coding “certification” by trade associations can a useful measure of a coder’s willingness to seek independent verification, it does nothing to assure that coders have the clinical tools they need to appreciate medical decision-making. In fact, the result of a non-clinician coder is often significant under-coding, a pervasive and relentless problem for most billing companies.

So, for our team of nurse coders throughout the country, Brault combines a proprietary certification program with frequent quality assessments and ongoing education on code definitions and reimbursement regulations.

Our coders are even trained to identify instances where critical care and observation care are being performed, but not adequately documented for billing purposes. By recognizing the clinical indicators that represent a “high probability of imminent or life threatening deterioration,” our coders can add extra value by prompting individual physicians to document time of attention (even days after the chart was presented for coding).

Proprietary Training for Clinical Understanding

In medicine today, there is a constellation of complaints, co-morbidities, patient history traits, treatment options, studies and interventions that practitioners must know about and consider. But, coders must also be fluent enough in this constellation to know which information is relevant, and which constitutes additional complexity.

And while coding “certification” by trade associations can a useful measure of a coder’s willingness to seek independent verification, it does nothing to assure that coders have the clinical tools they need to appreciate medical decision-making. In fact, the result of a non-clinician coder is often significant under-coding, a pervasive and relentless problem for most billing companies.

So, for our team of nurse coders throughout the country, Brault combines a proprietary certification program with frequent quality assessments and ongoing education on code definitions and reimbursement regulations.

Our coders are even trained to identify instances where critical care and observation care are being performed, but not adequately documented for billing purposes. By recognizing the clinical indicators that represent a “high probability of imminent or life threatening deterioration,” our coders can add extra value by prompting individual physicians to document time of attention (even days after the chart was presented for coding).

Proprietary Training for Clinical Understanding

In medicine today, there is a constellation of complaints, co-morbidities, patient history traits, treatment options, studies and interventions that practitioners must know about and consider. But, coders must also be fluent enough in this constellation to know which information is relevant, and which constitutes additional complexity.

And while coding “certification” by trade associations can a useful measure of a coder’s willingness to seek independent verification, it does nothing to assure that coders have the clinical tools they need to appreciate medical decision-making. In fact, the result of a non-clinician coder is often significant under-coding, a pervasive and relentless problem for most billing companies.

So, for our team of nurse coders throughout the country, Brault combines a proprietary certification program with frequent quality assessments and ongoing education on code definitions and reimbursement regulations.

Our coders are even trained to identify instances where critical care and observation care are being performed, but not adequately documented for billing purposes. By recognizing the clinical indicators that represent a “high probability of imminent or life threatening deterioration,” our coders can add extra value by prompting individual physicians to document time of attention (even days after the chart was presented for coding).

DO NOT SIMPLY STATE “FRACTURE“.  Describe the fracture as specifically as possible and laterality. Indicate the bones involved, whether it is open or closed, the type and degree of deformity and the distal neurovascular, cardiovascular status and functional status of the limb.

State exactly how the fracture was treated:  with open or closed treatment, manipulation or reduction, with or without anesthesia, and with casting, splinting or strapping.

Indicate whether you successfully reduced the dislocation with a procedure note.

Indicate the number of days before the patient is to seek follow-up care, or indicate whether you provided the major portion of the service by initial fracture management, or whether orthopedics is expected to provide the major initial service. If you believe you have performed the significant initial management of the fracture, state “restorative care provided by me.”

Usually, if follow-up must take place in less than 48 hours, initial fracture care is judged to have been deferred to the orthopedist with the emergency physician providing only stabilization of the injury.  If follow-up care can wait more than 48 hours, you are signaling that you have provided initial fracture care and can bill for it.

Example of billable fracture care documentation:

‘Final dx: Closed non-displaced fracture of 3rd distal phalanx.  Manipulation was not required.  Finger splint was applied by the nurse and checked by me post-application – NV status intact.  Patient to f/u with orthopedist in 5-7 days.’

If documentation does not meet aforementioned requirements, Fracture Care will not be coded/billed and deficiency code 8181 will be assigned for tracking purposes.

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