Acute Fracture VS Aftercare

[jbrightw]

A patient came to the office for ankle pain due to an injury 1 month before and the physician diagnosed as ankle sprain and found no fracture at that time and put him in a splint. A month later the patient comes again to the same physician with ankle pain and the physician performed an MRI ankle and diagnosed as distal fibula fracture and put him in an ankle brace. No new injury occurred.

What diagnosis code should be coded? As current Fracture code or aftercare of distal fibula fracture? Please help me.

Thanks

[mmpratt]

I would code it as a fracture on the current visit. Some fractures just don't show up until the physician observes new bone formation at a later visit. The term I often read is "occult."

[jbrightw]

Thanks