compression fractures
Does anyone have a query process for compression fractures? If so, how do you determine when to query for traumatic or non-traumatic. If the pt had a fall prior to admit I had not usually been asking for etiology but after some discussion with my co-workers am wondering if I should be querying for etiology even with fall, as diseased bone could cause the fracture with minor trauma? Any suggestions would be appreciated. Thanks!
Comments
Speaking one-on-one with the physician usually gets me the info. I want. But most of the time they do not know why/or what I am asking.
Its one of the more frustrating diagnoses I query. Our outside auditor was the one who came upwith the traumatic vs. Nontraumatic query.
N. Brunson, RHIA,CCDS
Insufficiency fracture
Stress fracture
Pathologic fracture
Osteoporotic fracture
Non-traumatic fracture
I usually present the patient's symptoms, scenario involved [injury out of proportion the trauma (slipping off the chair/toilet, etc.)], reference the x-ray showing diffuse osteopenia or diffuse degenerative bone disease (whatever the radiologist says), and any related meds (Actonel, Boniva, Evista, Fosamax, Calcitonin/Miacalcin), include any risk factors (post-menopausal, previous steroid/anti-inflammatory drug therapy, lack of estrogen replacement, etc., and ask them:
"Do you feel that the above information supports one of the following more specific diagnosis? If so, please add this documentation to your next progress note and discharge summary"
a) osteoporotic fracture or fracture associated with osteoporosis
b) stress fracture
c) insufficiency fracture
d) non-traumatic fracture
e) traumatic fracture
f) other _______________
g) undetermined