auditqueen
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This question is related to determining the E/M level for professional coding within the Emergency Department. The patient presents with a suspected ankle fracture. Physician performs all of the key elements (HPI, ROS, PFSH, Physical Exam) and orders an xray to determine whether or not the ankle is fractured. The xray returns a negative result, the ankle is sprained not fractured. The presenting problem was a possible ankle fracture, the final diagnosis is ankle sprain. Ace bandage was applied and patient was sent home without any medications. Would this be coded as a level 3 due to presenting problem of acute complicated injury, or would this be coded as a level 2 due to the final diagnsis of an acute uncomplicated illness? Thank you.