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have become incredibly onerous. This week I finished seeing patients
at 4:30 p.m. Monday and concluded dictating at 3 p.m. Tuesday. When
my coding is complete, there are more entries than the captain's log
book on Noah's Ark. Let's look at the documentation necessary for
fracture care (the mnemonic LEO C FAR applies):
L Location and laterality. I hope we get this right.
E Encounter (initial or subsequent).
Tell the truth, Doc! Initial pays more.
O Open or closed? Duh!
C Classification. Choose your weapon.
C Category of fracture (growth plate, pathologic, stress). Aren't all
fractures stressful?
C Cause (medications, age, trauma). Do in-laws apply?
F Fracture pattern (transverse, spiral, comminuted). How about
"weird?"
A Alignment (displaced, non-displaced). Does "pretty good" work?
R Result (routine healing, delayed healing, non-union, etc.). Make sure
no lawyer is
within a 5-mile radius.
Indications for surgery
Operative notes are no picnic either. ICD-10 requires "indications for
surgery" in the formal operative report. Surgeons have to document
why the patient was brought to the OR. Catchphrases such as "6
months of failure of conservative therapy" may suffice. Other termi-
nology such as "I thought he needed it" or "I was behind on my car
payments" won't fly.
Exact findings at surgery must be well-annotated. Expressions such
as "The rotator cuff was jacked up" will result in insurance denial —
C U T T I N G R E M A R K S
