Patient presents with left elbow pain following a fall onto an outstretched hand.  Mechanism of injury is consistent with a possible left elbow fracture.  Patient reports immediate pain and limited range of motion.  Physical examination reveals swelling, tenderness to palpation, and ecchymosis around the left elbow joint.  Neurovascular examination of the left hand reveals intact sensation and capillary refill.  Radiographic imaging of the left elbow including AP, lateral, and oblique views was ordered to evaluate for fracture.  Radiology report confirms a left elbow fracture involving the distal humerus.  Diagnosis of left elbow fracture ICD-10 code S42 is confirmed.  Differential diagnoses considered included elbow sprain, dislocation, and radial head fracture.  Treatment plan includes pain management with analgesics, immobilization with a splint or sling, and orthopedic consultation for definitive management.  Patient education provided on fracture care, activity modification, and follow-up appointments.  Prognosis is dependent on fracture type and severity.  Follow-up scheduled with orthopedics in one week for evaluation and potential surgical intervention if indicated.  Potential complications discussed with the patient including infection, stiffness, nonunion, malunion, and complex regional pain syndrome.  Patient understands the risks and benefits of treatment and agrees with the plan of care.  Medical coding includes CPT codes for the evaluation and management services provided as well as the radiology procedures.  Billing information was reviewed with the patient.