Orthopedic Coding Alert

Question: A new patient reports to the orthopedist with a badly bruised left ankle. After a level-four evaluation and management (E/M) service, the orthopedist takes a two-view ankle X-ray, which comes back negative. The orthopedist then counsels the patient on treating the injury and sends him home. Final diagnosis was “L ankle sprain, tib-fib lig.” What is the correct coding for this encounter?

Florida Subscriber

Answer: First, you’ll report 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity …) for the E/M service. Then, report 73600 (Radiologic examination, ankle; 2 views) for the X-ray.

As for ICD-10 codes, you’ll append S93.432A (Sprain of tibiofibular ligament of left ankle, initial encounter) to 99204 and 73600 to represent the patient’s injury.