Radiology Coding Alert

Question: A patient presents to urgent care complaining of severe right ankle pain after twisting it while playing football in the park. The patient’s ankle is swollen and discolored. Following history and a physical examination, the physician orders X-rays of the patient’s ankle to check for a fracture. The radiologist captures anteroposterior (AP), internal oblique, and lateral X-ray views of the ankle and reports their findings. The patient is diagnosed with “R ankle sprain, tib-fib lig.”

What codes do I need to report for the X-rays and diagnosis?

Massachusetts Subscriber

Answer: Starting with the procedure code, you’ll want to choose a three-view X-ray CPT^® code since the radiologist captured AP, internal oblique, and lateral views. For this procedure, you’ll assign 73610 (Radiologic examination, ankle; complete, minimum of 3 views) to report the X-rays. You can also append the CPT^® code with modifier RT (Right side) to indicate laterality.

The patient was diagnosed with a right ankle sprain of the tibiofibular ligament. In the ICD-10-CM code set, you’ll assign S93.431A (Sprain of tibiofibular ligament of right ankle, initial encounter) for the diagnosis. In the Alphabetic Index, search for Sprain (joint) (ligament) > ankle > tibiofibular ligament, which provides you with S93.43 (Sprain of tibiofibular ligament) that you’ll then verify in the tabular list. In the tabular list, a 6th character is required to indicate laterality and a 7th character is required to complete the code.

In this case, 6th character “1” indicates the right ankle and 7th character “A” denotes the visit as an initial encounter.