Radiology Coding Alert

Question: A 21-year-old male patient visited our after-hours care center complaining of right ankle pain after twisting it while walking home late at night. The report I have shows the radiologist captured three X-ray views and performed a CT scan to check for tendon damage. The findings indicate a sprained ankle with no bone fractures.

Can you walk me through coding this visit?

North Carolina Subscriber

Answer: In this scenario, you’ll start by coding the appropriate procedure codes. In this case, the report notes that the radiologist captured three views with X-rays, so you’ll use 73610 (Radiologic examination, ankle; complete, minimum of 3 views). Additionally, the report should state the types of views performed to support your code selection. Next, the radiologist performed a computed tomography (CT) scan to check for tendon damage. You’ll use 73700 (Computed tomography, lower extremity; without contrast material) to report the CT scan.

Following the procedure codes, you’ll need to code the diagnosis for the patient, which is the sprained ankle. When you look up Sprain > ankle in the Alphabetical Index of the ICD-10-CM code set, you are directed to S93.40. In the tabular list, S93.40 brings you to Sprain of unspecified ligament or ankle, but with further digging, you’ll find S93.401 (Sprain of unspecified ligament of right ankle). However, S93.401 carries a 7th character, which indicates you’ll need to add “A” to the end of the ICD-10-CM code to reflect the initial encounter.