Radiology Coding Alert

Question: A patient presented with swelling from their left knee down to their foot and severe pain. The radiologist captured anteroposterior (AP), posteroanterior (PA), and lateral views of the left foot and ankle to check for fractures. The impressions are negative for fractures.

How do I report this encounter?

New York Subscriber

Answer: You’ll need two CPT^® codes and several ICD-10-CM codes to report this encounter. Starting with the procedures, you’ll assign the following X-ray codes:

• 73610 (Radiologic examination, ankle; complete, minimum of 3 views)
• 73630 (Radiologic examination, foot; complete, minimum of 3 views)

The radiologist captured three-view X-rays of the ankle and the foot to assess the structures for fractures. You might also append modifier LT (Left side) to the codes to indicate the provider performed the procedure on the left side of the body, but check the individual payer preferences to see how they want the codes reported.

Next, you’ll turn to the ICD-10-CM code set. In this situation where the radiologist didn’t find any fractures, you’ll need to report the signs and symptoms for the visit. The patient presented with swelling and pain in their lower leg, ankle, and foot, which means you’ll need the appropriate codes to cover those signs in those anatomical structures.

For the swelling, you’ll assign M79.89 (Other specified soft tissue disorders) to report the lower leg and foot swelling and M25.472 (Effusion, left ankle) to report the left ankle swelling. Next, you’ll turn your attention to the patient’s pain. Code M79.662 (Pain in left lower leg) covers the leg pain, M79.672 (Pain in left foot) represents the left foot pain, and M25.572 (Pain in left ankle and joints of left foot) is used to report the left ankle pain.