Wiki Inpatient Initial E&M

I am having a little issue and confusion on what the correct level should be for a patient with a pathologic subtrochanteric femur fracture. The main issue is what the correct number and complexity of problem should be. If anyone could be please help with this, please let me know based on the note below. Thank you for any help.


I saw and evaluated the patient. I discussed the case with the resident, and I agree with the findings and plan as documented in resident’s note.

In brief, Patricia Ann Jackson is a 59 y.o. female whose mechanism of injury was falling while playing with her grandchildren on monkey bars. Describes pain as moderate and severe and localized to her left hip and thigh with exacerbation with motion and alleviation with rest, pain medication, and immobilization.

PE reveals traction in place. She has soft compartments. There are no signs of compartment syndrome. She has swelling of her left thigh. No open wounds are noted. She has a normal neurovascular exam distally.

Imaging studies reveal a displaced subtrochanteric femur fracture. There is lateral cortical beaking. There was an oblique fracture pattern. This is consistent with a bisphosphonate type fracture pattern for a stress fracture pattern. She has been on bisphosphonates for a prolonged time.

She is not having any contralateral hip or thigh pain. Radiographs were ordered of the contralateral side which showed no cortical thickening or beaking on that side. There is no evidence of a stress reaction on that side. She was not having any prodromal pain on that side.

Assesment:
1. Left pathologic subtrochanteric femur fracture, related to osteoporosis and consistent with a bisphosphonate pattern


Plan:
1. Admission
2. Operative treatment for stabilization of left subtrochanteric femur fracture
3. Postoperative antibiotics and pain control
4. Mobilization with physical therapy. She will be weight-bearing as tolerated on her left lower extremity.
5. Expected discharge with likely be postoperative day two if she is able to safely mobilize and comfortable.

What do you think about Acute, uncomplicated illness or injury requiring hospital inpatient or observation level care? As defined by CPT: "a recent or new short-term problem with low risk of morbidity for which treatment is required. there is little to no risk of mortality with treatment, and full recovery without functional impairment is expected. The treatment required is delivered in a hospital inpatient or observation level setting".

Ortho definitely not my wheelhouse, but I would think this is more than low for acute, uncomplicated illness. I would consider a fracture in a younger, healthier patient, or a non-displaced fracture to be acute, uncomplicated.
I would likely consider this problem acute, complicated as they are treating operatively for a displaced fracture in a patient with osteoporosis

Acute, complicated injury: An injury which requires treatment that includes evaluation of body systems that are not directly part of the injured organ, the injury is extensive, or the treatment options are multiple and/or associated with risk of morbidity.

Acute complicated. It's drug related. "bisphosphonate type fracture pattern", "She has been on bisphosphonates for a prolonged time", " osteoporosis".
They'll be putting hardware into an osteoporotic patient with a pathologic fracture which may or may not have occurred with this mechanism of injury for a patient who was not on bisphosphonates.

This is an acute complicated injury.
It is multi-system, associated with significant morbidity and potential loss of limb function.
Anything less would be -grossly- underselling it.

For the record, there is not a femur fracture that I can imagine that would be considered acute uncomplicated.
This is a femur fracture - a profound injury, requiring surgery. Even a nondisplaced greater troch fracture has the potential for severe morbidity if untreated or undertreated.