Anesthesia Coding Alert

Question: We have a patient chart from an office visit that includes an x-ray of the patient's ankle and a diagnosis of pain. One of our coders says to treat it as general pain, but another says to code it as ankle pain because of the x-ray. Which diagnosis is better?


Delaware Subscriber

Answer: The x-ray could serve as a clue, but don't code based on the assumption that the patient has ankle pain. Instead, ask the physician for a more definitive diagnosis before coding the case.

If you're reporting an office visit for the patient whose main complaint is ankle pain, a diagnosis such as 719.47 (Pain in joint; ankle and foot) could apply. If you can't determine that the ankle pain diagnosis is correct, report a more general diagnosis for the visit such as 729.5 (Pain in limb).

Report the office visit with the appropriate choice from 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) or 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...), depending on whether the patient is new or established in your practice.