Vertebral fractures

Vertebral Fracture

In vertebral fractures, document the following:

• Identify the specific anatomical location of the fracture (e.g., fourth lumbar vertebra, seventh cervical vertebra, T 5-6, etc.)

• Indicate the type of fracture (e.g., in this case, traumatic, pathological, stress, wedge compression, Type II, burst, etc.).

• List the level of any spinal cord injury.

• Provide information regarding the activity, location, and circumstances surrounding the injury when possible.

• Specify any associated or underlying disease (e.g., osteoporosis).

• Clarify open versus closed fractures.

• Indicate if the encounter is for initial, subsequent, or sequela treatment.