Wiki Fractures with tendon injury

LLRodgers

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I have a patient that on 6/18/15 the diagnosis was

1. Subacute medial malleolar avulsion fracture
2. Peroneal Tendon Subluxation

On 7/2/15 the Diagnosis was 1. Bone bruise of medial malleolus, old ossification center 2. Subluxation of the peroneal tendon. No mention of the fracture

On 7/8/15 the diagnosis was 1. Peoneal tendionpathy 2. Sanpping peroneal tendon

I coded a fracture care on the first visit, should I have coded the fracture separate with a fracture care code an then the subluxation with a straight e/m code?

Since there is no mention of a fracture now can I start using a straight E/M code?

Thank you,

LLR
 
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