Use the CPT, ICD-9-CM, and ICD-10-CM manuals to assign the appropriate Emergency department visit, procedure, modifier, and diagnoses codes to the following case scenario.
1. Use the CPT, ICD-9-CM, and ICD-10-CM Manuals to assign the appropriate Emergency department visit, procedure, modifier, and diagnoses codes to the following case scenario.
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.
CPT codes: ________________ , _________________
ICD 9 Codes: __________________ , _______________________
ICD 10 Codes : _________________ , ________________________
99281 73600 S82.54 W01.xxA
To assign the appropriate codes to the given case scenario, we will need to consult the CPT, ICD-9-CM, and ICD-10-CM manuals.
1. Emergency department visit code (CPT):
Since the case scenario does not provide specific information about the level of the emergency department visit, such as the complexity, time spent, or any additional services provided, we will assume a straightforward level for this assignment. In CPT, a straightforward level of emergency department visit is typically represented by code 99282.
CPT code for emergency department visit: 99282
2. Procedure code for the immobilization of the ankle (CPT):
Based on the description, the physician immobilized the patient's ankle. In CPT, code 29405 represents the initial casting or strapping of the ankle.
CPT code for immobilization of the ankle: 29405
3. Modifier (CPT):
No specific modifiers are mentioned in the case scenario. However, if any additional circumstances or complexity were present during the visit, appropriate modifiers should be applied as required.
Modifier: None specified
4. Diagnosis codes (ICD-9-CM and ICD-10-CM):
The case scenario provides information about the patient's injury and the subsequent diagnosis by the radiologist. To assign the appropriate diagnosis codes, we will need to consult the ICD-9-CM and ICD-10-CM manuals.
ICD-9-CM diagnosis code for ankle injury:
Based on the description of a "simple closed fracture of the medial malleolus," the appropriate ICD-9-CM diagnosis code would be 824.8, representing the fracture of the lower end of the fibula (with or without the lower end of the tibia) or the ankle, closed.
ICD-9-CM diagnosis code: 824.8
ICD-10-CM diagnosis code for ankle injury:
In ICD-10-CM, the appropriate diagnosis code for a simple closed fracture of the medial malleolus would be S82.60, representing a fracture of the medial malleolus of the leg, unspecified side.
ICD-10-CM diagnosis code: S82.60
To get the full code, including the extension for laterality (right), we need to use the additional digits available in ICD-10-CM. Therefore, the appropriate ICD-10-CM diagnosis code for this case scenario would be S82.601A, representing a simple closed fracture of the right medial malleolus.
ICD-10-CM diagnosis code (including laterality): S82.601A
In summary:
CPT codes: 99282, 29405
ICD-9-CM diagnosis code: 824.8
ICD-10-CM diagnosis code: S82.601A