Podiatry Coding & Billing Alert

Question: We often get patients with painful foot/ankle subluxation and sprains. Do we have any guidelines regarding the documentation requirements for an initial visit that help us prove the medical necessity?

Pennsylvania Subscriber

Answer: Definitely, yes. CMS requires appropriate documentation of patient’s initial visit examination proceedings.

Starting from penning the patient’s history, which should include symptoms, relevant family history, past medical and surgical history, mechanism of injury, if any, which has caused the presenting symptoms, record a detailed description of symptoms including onset, duration, intensity, frequency, location and radiation, aggravating or relieving factors; and details of prior treatment and medications taken, if any. Make sure that the symptoms the patient narrates have a direct bearing on the level of foot sprain injury that you would identify.

What’s more, the symptoms must refer to the muscle (myo), bone (osseo or osteo), or joint (arthro) and be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc. While describing pain, be specific to indicate the location and its probable relation to the particular region on the foot to have been affected.

You then do evaluation of the underlying musculoskeletal/nervous system through physical examination. As for the diagnosis, your first or primary diagnosis must be ankle sprain (845.0x, Ankle sprain) or foot sprain (845.1x, Foot sprain), and indicating the exact site level of the sprain reported by the more detailed code from the 845 code set. Such terms may refer either to the condition of the joint involved (if any) or to the direction of foot position assumed by the particular bone named. After the recent ICD-10 implementation, you should report the sprains by using appropriate codes from the ICD-10 code groups S93.4-- (Sprain of ankle), S93.6 (Sprain of foot), and S93.5-- (Sprain of toe).

Your treatment plan must include specific objectively measurable treatment goals, and the frequency of visits that you recommend. Lastly, remember to mention the date of the initial treatment.