Primary Care Coding Alert

Question: A patient presented with an ankle sprain, and the physician told him to rest it and wrap it. Two months later, the ankle had not improved. The doctor went in with a scope and repaired the patient's tendons and ligaments. Should we use the diagnosis code for ankle sprain (845.00) or for history of ankle sprain?

California Subscriber

Answer: If the patient is still receiving treatment, the condition is current, and you should report the ankle sprain code; but if the treatment ends, use the code indicating history of (e.g., V15.5, Other personal history presenting hazards to health; injury). In your case the treatment is continuing and the patient never recovered from the old injury, so do not use V15.5. But using 845.00 (Sprains and strains of ankle and foot; ankle, unspecified site) may also compromise your reimbursement because it is an unspecified code.

Read the physician's operative note, or ask him or her to determine exactly which tendon/ligaments were repaired so you can select the most accurate diagnosis code. Code 845.00 refers to an unspecified site, but at this point the physician has specifically repaired either a tendon and/or ligament, and the ICD-9 code selected needs to reflect this injury (e.g., 845.01, Sprains and strains of ankle and foot; deltoid [ligament], ankle).