Orthopedic Coding Alert

Question: Encounter notes indicate that the patient suffered from a “stress Fx RT ankle/foot/great toe.” How do I choose a diagnosis code — or codes — for this injury?

Illinois Subscriber

Answer: You’ll actually want to include three codes: one for each injured area of the ankle/foot. On the claim, report:

• M84.371- (Stress fracture, right ankle) for the ankle stress fracture
• M84.374- (Stress fracture, right foot) for the foot stress fracture
• M84.377- (Stress fracture, right toe(s)) for the great toe fracture

Don’t forget: All of these codes go to the 7th character, meaning you’ll have to choose from the following characters to code the patient’s injuries fully:

• A = initial encounter for fracture
• D = subsequent encounter for fracture with routine healing
• G = subsequent encounter for fracture with delayed healing
• K = subsequent encounter for fracture with nonunion
• P = subsequent encounter for fracture with malunion
• S = sequela.