Pediatric Coding Alert

Question: An adolescent patient came in after turning his ankle playing soccer. Our pediatrician examined the patient and decided that he needed to go to the emergency room (ER) for an X-ray, as she believed he may possible have torn ligaments around the right ankle. How should I code this encounter? Would I use R22.41, M25.571, or S99.911A?

AAPC Forum Participant

Answer: In this scenario, ICD-10 guideline 1.C.13.b., one of the specific guidelines for the chapter 13 (Diseases of the Musculoskeletal System and Connective Tissue) codes M00-M99 tells you that “chronic or recurrent conditions should generally be coded with a code from chapter 13,” but “any current, acute injury should be coded to the appropriate injury code from chapter 19.”

This would suggest that S99.911A (Unspecified injury of right ankle, initial encounter) would be a more appropriate code than M25.571 (Pain in right ankle and joints of right foot), because the injury code more accurately describes the acute nature of the patient’s current condition. The musculoskeletal code would be more appropriate for conditions that affect the patient over an extended period of time, such as a condition that is the result of a previous injury.

However, the guideline also goes on to tell you that “if it is difficult to determine from the documentation in the record which code is best to describe a condition, query the provider.” This means you should not rule out R22.41 (Localized swelling, mass and lump, right lower limb) if your provider decided that, in the absence of X-ray evidence, a signs and symptoms code is a more appropriate diagnosis for the patient’s current situation.