Radiology Coding Alert

Question: I have a radiology report where the radiologist’s findings are listed as a displaced closed lateral and medial malleoli right ankle fracture. The radiologist captured anteroposterior (AP), lateral, and mortise views of the patient’s right ankle.

What codes should I assign for this encounter?

Maine Subscriber

Answer: Starting with the radiology procedure, you’ll assign 73610 (Radiologic examination, ankle; complete, minimum of 3 views) to report the three-view ankle X-rays. Next, you’ll turn to the ICD-10-CM code set for the diagnosis.

The report shows fractures in two different bones — the medial malleolus and the lateral malleolus. The medial malleolus is made of the medial (distal) end of the tibia, while the lateral malleolus consists of the distal (outside) end of the fibula. This means that the patient experienced a bimalleolar ankle fracture, but you’ll only need S82.841A (Displaced bimalleolar fracture of right lower leg, initial encounter for closed fracture) to report the diagnosis.

Why? When you open the ICD-10-CM Alphabetic Index to locate Fracture, traumatic (abduction) (adduction) (separation) > ankle > bimalleolar (displaced), you’ll find S82.84- (Bimalleolar fracture of lower leg). After turning to the Tabular List, you’ll discover that S82.84- requires 6^th and 7^th characters to complete the code.

The 6^th character identifies whether the fracture was displaced or nondisplaced and specifies the laterality. You’ll then use 7^th character A to identify that the patient presented for an initial encounter for a closed fracture.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC