Step up to Code This Ankle Injury
Question: A patient who injured their left ankle after falling from a ladder reports to the orthopedist; it is the initial encounter to address this injury. After a physical assessment and examination, the orthopedist orders a two-view ankle X-ray, which reveals a closed pilon fracture at the lower end of the tibia. In order to get a better view of the fracture, the orthopedist orders an MRI without contrast material. How should I report this encounter? Iowa Subscriber Answer: To properly code this encounter, you will need three CPT® codes and two ICD-10-CM codes on your claim. Start by assigning 73721 (Magnetic resonance (eg, proton) imaging, any joint of lower extremity; without contrast material) for the MRI without contrast material. Next, you’ll use 73600 (Radiologic examination, ankle; 2 views) for the X-rays. Also, append modifier LT (Left side) to 73721 and 73600 to indicate laterality. Next, you’ll need an appropriate evaluation and management (E/M) code based on setting and encounter notes. Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the appropriate E/M code to show that the E/M service and the imaging services were significant and separately identifiable. Lastly, turn to the ICD-10-CM code book to assign codes for the injury and what occurred to cause the patient’s injury. Append code S82.872A (Displaced pilon fracture of left tibia, initial encounter for closed fracture) to 73721, 73600, and the E/M code to show the reason for the treatment. Then, append W11.XXXA (Fall on and from ladder, initial encounter) to 73721, 73600, and the E/M code to indicate how the patient suffered the broken ankle. Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
