Orthopedic Coding Alert

Question: Notes indicate the provider performed a level-four office evaluation and management (E/M) service for an established patient that lasted 42 minutes and included moderate medical decision making (MDM). Final diagnosis was “displ. Osteochon. Fx, L patella.” How should I report this encounter?

Maine Subscriber

Answer: You’ll report 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) for the E/M.

Your choice for the ICD-10 code isn’t completely clear from the encounter description. You’ll report S82.012- (Displaced osteochondral fracture of left patella) for the patient’s injury — but don’t stop there.

All diagnosis codes in the S82 (Fracture of lower leg, including ankle) code set require a 7th character. So go back and check the notes and choose one of these 7th character options to add to S82.012-:

• A = initial encounter for closed fracture
• B = initial encounter for open fracture type I or II
• initial encounter for open fracture NOS
• C = initial encounter for open fracture type IIIA, IIIB, or IIIC
• D = subsequent encounter for closed fracture with routine healing
• E = subsequent encounter for open fracture type I or II with routine healing
• F = subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing
• G = subsequent encounter for closed fracture with delayed healing
• H = subsequent encounter for open fracture type I or II with delayed healing
• J = subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing
• K = subsequent encounter for closed fracture with nonunion
• M = subsequent encounter for open fracture type I or II with nonunion
• N = subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion
• P = subsequent encounter for closed fracture with malunion
• Q = subsequent encounter for open fracture type I or II with malunion
• R = subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion
• S = sequela.