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Primary Care Coding Alert

Reader Questions:

Multiple X-Ray Charges OK for Different Purposes

Published on Wed May 18, 2011

Question: A new patient presented to the office because of an injured left ankle she hurt while doing yard work. The FP performed a detailed history and examination. He suspected a fracture and ordered a two-view ankle x-ray, which revealed a bimalleolar fracture. The physician provided local anesthesia and used closed treatment to manipulate the fracture. He then ordered a second two-view ankle x-ray to confirm proper alignment. Notes indicated moderate medical decision making. Can I code both ankle x-rays in this scenario?Illinois SubscriberAnswer: Since the physician ordered separate x-rays for different purposes (identifying the fracture, then ensuring proper bone placement), you can code for both. On the claim, report the following:99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history;, a detailed examination; and medical decision making of low complexity) for the evaluation and management [...]
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