Radiology Coding Alert

Question: A patient presented to our radiology practice for a follow-up appointment of their closed nondisplaced fracture of the lateral epicondyle in their left elbow. A physician at a nearby emergency department performed the initial treatment three weeks before. During this encounter, the radiologist captured three views of the patient’s elbow, and noted the injury is healing correctly.

How do we report this encounter?

Pennsylvania Subscriber

Answer: Two codes are needed to report this encounter — one procedure code and one diagnosis code.

Starting with the procedure, you’ll assign 73080 (Radiologic examination, elbow; complete, minimum of 3 views) to report the three-view elbow X-ray. Make sure the images are permanently recorded in the medical record and the record includes documentation of the views. Also, review your individual payer preferences to confirm whether you’ll need to append a laterality modifier, such as LT (Left side) or RT (Right side), to 73080.

Next, you’ll assign S42.435D (Nondisplaced fracture (avulsion) of lateral epicondyle of left humerus, subsequent encounter for fracture with routine healing) to report the reason for the visit. In this case, the patient presented for follow-up X-rays of their elbow fracture. The radiologist noted that the injury is healing correctly.

According to the ICD-10-CM Official Guidelines, 7th character “D” is used for subsequent encounters “after the patient has completed active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.”