Radiology Coding Alert

Question: We have a patient who underwent a 3-view ankle X-ray for a left, displaced lateral malleolus fracture in addition to a 2-view X-ray for left, upper end fibular fracture. Should I include both diagnoses codes on both procedures?

Minnesota Subscriber

Answer: In your example, you should not designate both diagnosis codes to both procedures, despite the fact that the fractures are within close proximity to one another. Just as you would if the provider performs the X-rays on entirely separate anatomic sites (i.e. left leg, right leg), you will only apply the diagnosis relevant to each respective scan. This remains true even if the radiologist images and documents both diagnoses on both X-rays.

For the 3-view ankle X-ray of the left, dispalced lateral malleolus fracture, you will apply code 73610 (Radiologic examination, ankle; complete, minimum of 3 views). For the 2-view X-ray of the left proximal fibular fracture, you will apply code 73590 (Radiologic examination; tibia and fibula, 2 views).

As for the diagnoses, you will attach S82.62XA (Displaced fracture of lateral malleolus of left fibula, initial encounter for closed fracture) to 73610. You will then attach S82.832A (Other fracture of upper and lower end of left fibula, initial encounter for closed fracture) to code 73590.