For ER encounters, if a patient comes in with a fracture that the MD documents as "age uncertain", is that coded as an acute finding? I cannot find any literature on this. Coworker is stating to code it as "other disorders of bone" which does not sound right.
My thought process is that even if the fx may or may not have been not caused by an accident, it is the first time it is being addressed...
this is specific to outpatient ER coding. We get a lot of radiology reports with the indication being "trauma" or whatever the accident was (eg "fall" "MVC"). My question is, is it appropriate to code an unspecified injury code that is site specific when the indication states that, or should I stick with using Z04 codes as primary when there is no symptom/finding?
I have coworkers on both sides of the fence with this dilemma. One of my coworkers says that since trauma has a 'see also' note that directs to injury, to use an S code. If that is the case then why would Z04- even exist? Curious to see what other ER coders use and their logic.
Thanks!