What are the CPT and ICD codes for this case?
Gladys Swain slipped from a sidewalk curb and twisted her right ankle. Because of the severe pain she was suffering and the inability to bear weight on the foot, she sought treatment at her neighborhood hospital emergency department. The treating physicians were fairly confident that Ms. Swain had an ankle injury. The physician completed a problem-focused history regarding the injury and a problem-focused physical examination of her right foot and ankle. The MDM complexity was straightforward. The patient was immediately sent to the radiology department for an x-ray. A two-view x-ray of the right ankle was completed. The radiologist confirmed a simple closed fracture of the medial malleolus. The patient then returned to the emergency department, where the physician immobilized the ankle. The patient was referred to an orthopedic surgeon. Code the emergency department service and the radiology service.
What are the CPT and ICD codes for this case?
Gladys Swain slipped from a sidewalk curb and twisted her right ankle. Because of the severe pain she was suffering and the inability to bear weight on the foot, she sought treatment at her neighborhood hospital emergency department. The treating physicians were fairly confident that Ms. Swain had an ankle injury. The physician completed a problem-focused history regarding the injury and a problem-focused physical examination of her right foot and ankle. The MDM complexity was straightforward. The patient was immediately sent to the radiology department for an x-ray. A two-view x-ray of the right ankle was completed. The radiologist confirmed a simple closed fracture of the medial malleolus. The patient then returned to the emergency department, where the physician immobilized the ankle. The patient was referred to an orthopedic surgeon. Code the emergency department service and the radiology service
To code the emergency department service and the radiology service for this case, you would need to determine the appropriate Current Procedural Terminology (CPT) codes and International Classification of Diseases (ICD) codes.
For the emergency department service, the appropriate CPT code is typically chosen based on the level of Evaluation and Management (E/M) service provided. Since the case mentions a problem-focused history and physical examination, as well as straightforward medical decision making (MDM) complexity, the most appropriate E/M code would likely be a level 2 established patient visit (99282).
For the radiology service, you would need to identify the appropriate CPT code for the two-view x-ray of the right ankle. The code for this specific service would be 73610 (Radiologic examination, ankle; 2 views).
Additionally, you would also need an appropriate ICD code to describe the fracture of the medial malleolus. The ICD-10 code for a closed fracture of the medial malleolus would be S82.41 (Unspecified fracture of lower end of right tibia).
So, the CPT code for the emergency department service would be 99282, the CPT code for the radiology service would be 73610, and the ICD-10 code for the fracture would be S82.41
To determine the CPT and ICD codes for this case, we will need to analyze the information provided.
CPT codes (Current Procedural Terminology) are used for reporting medical procedures and services. ICD codes (International Classification of Diseases) are used for diagnosing and documenting medical conditions.
In this case, the patient Gladys Swain slipped and twisted her right ankle, resulting in severe pain and the inability to bear weight on the foot. She sought treatment at her neighborhood hospital emergency department.
The physician completed a problem-focused history and a problem-focused physical examination of her right foot and ankle, indicating that the E/M service provided was of low complexity. Therefore, we can choose an appropriate E/M code from the Emergency Department services category.
For the radiology service, a two-view x-ray of the right ankle was performed, confirming a simple closed fracture of the medial malleolus. We will need to find the appropriate CPT code for this radiology procedure.
Lastly, we will need to find the ICD code to document the ankle injury.
To find the specific CPT and ICD codes, you would ideally refer to a coding resource such as the Current Procedural Terminology (CPT) codebook and the International Classification of Diseases (ICD) codebook or an electronic coding system.
CPT codes for Emergency Department services typically fall under the 99281-99285 code range. Considering that the patient's case involved a straightforward medical decision making (MDM) complexity, you can use a lower-level E/M code such as 99282.
For the radiology service, you will need to identify the appropriate CPT code for a two-view x-ray of the right ankle. This may involve reviewing the CPT codebook or referring to an electronic coding system.
To document the ankle injury, you will need to find the appropriate ICD code that represents a simple closed fracture of the medial malleolus. This may involve searching for the specific ICD-10 code related to ankle fractures.
Please note that the exact CPT and ICD codes may differ based on the details of the case and any additional procedures or services provided. It is essential to consult coding resources or seek assistance from a certified medical coder for accurate and up-to-date code selection.