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 diagnoses, emergency department service, and radiology service in the following order
ICD-9-CM Code:
ICD-9-CM Code:
CPT Code:
CPT Code and Modifier:
im not sure. could someone help me with this?
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 diagnoses, emergency department service, and radiology service in the following order
ICD-9-CM Code:
The ICD-9-CM code for a simple closed fracture of the medial malleolus is 824.8.
Emergency Department Service:
The Emergency Department Service can be coded using Evaluation and Management codes. In this case, the code would be 99284, which represents a comprehensive level of evaluation and management service for a moderately severe problem.
Radiology Service:
The radiology service for the two-view x-ray of the right ankle can be coded using the appropriate CPT code. In this case, the code would be 73620, which represents a two-view x-ray of the ankle.
Orthopedic Surgeon Referral:
The orthopedic surgeon referral is not provided in the given information, so it cannot be coded.
In order to code the diagnoses, emergency department service, and radiology service in ICD-9-CM and CPT, we need to identify the correct codes based on the information provided.
1. The diagnoses for this case are a "simple closed fracture of the medial malleolus" and an ankle injury. However, the specific ICD-9-CM codes for these diagnoses are not provided.
To find the appropriate ICD-9-CM codes, you can use an ICD-9-CM code book or search for the specific diagnosis codes online. Look for codes related to ankle fractures and ankle injuries.
2. The emergency department service performed was a problem-focused history and physical examination, as well as immobilization of the ankle. Again, specific CPT codes are not provided.
To find the CPT code for the emergency department service, you can use a CPT code book or search for the specific CPT code online. Look for codes related to emergency department services or evaluation and management (E/M) codes.
3. The radiology service performed was a two-view x-ray of the right ankle. The radiologist confirmed the simple closed fracture of the medial malleolus.
To find the CPT code for the radiology service, you can use a CPT code book or search for the specific CPT code online. Look for codes related to x-rays and the specific views performed.
It is important to note that without the specific diagnosis codes and CPT codes provided, I cannot give you the exact codes for this case. I recommend consulting an official ICD-9-CM and CPT code source or consulting a certified medical coder for accurate and specific coding information for this case.