Podiatry Coding & Billing Alert

Use the scenario details to arrive at an answer.

In your podiatry practice, it’s highly likely you must code claims for common ankle injuries. So, it’s never a bad idea to get back to the basics of coding with a specific clinical scenario. Keep reading to see if you know how to report the scenario, then check out the breakdown of the correct codes to test your answers.

Scenario:
A 32-year-old established female patient comes into the office with a swollen right ankle. She is experiencing pain in her right ankle and joints. She sustained this injury after tripping over a rake and falling in her backyard. The podiatrist takes three X-ray images of the patient’s ankle to see what was causing the swelling and pain and to rule out a possible fracture. The podiatrist took one image of the front (anteroposterior view, or AP) of the ankle, one from the side (lateral view), and one at a mortise view. The podiatrist documents that he spends 15 minutes with the patient obtaining an expanded problem focused history and an expanded problem focused exam of her right ankle. He also documents that he uses medical decision making of low complexity.

Break Down Your CPT^® Codes

E/M: For the evaluation and management (E/M) code for this office visit, you would report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity...).

Although there are multiple other E/M codes to choose from, 99213 is the correct option because according to the medical documentation, the podiatrist obtained an expanded problem focused history, an expanded problem focused exam, and used medical decision making of low complexity. This fits 99213’s code descriptor.

Established vs. new patient: You should note that in this case, the patient is established, which is an important detail you must consider when reporting E/M codes. For a new patient, you would have looked at codes 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making …)-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity…). For an established patient, you should look to 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making…)-99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity…).

Key components: For new patients, the physician must perform all three key components as indicated by the code descriptors for you to correctly report codes 99201-99205. On the other hand, for established patients, the physician must perform “at least two of the three key components,” as indicated by the descriptors, for you to appropriately report codes 99212-99215.

X-ray: For the X-ray service, you should report 73610 (Radiologic examination, ankle; complete, minimum of 3 views).

You would report 73610 because the podiatrist documented that he took three X-ray images of the patient’s ankle. He also documented what type of views he took. According to 73610’s code descriptor, to report 73610, the physician must have taken a minimum of three X-ray images. If, for example, the podiatrist had only taken two X-ray images of the patient’s ankle, then you should have reported 73600 (Radiologic examination, ankle; 2 views) instead.

Don’t Miss Your ICD-10 Codes

Upon completing the X-rays, the podiatrist discovered that the patient did not have a fractured ankle.

The podiatrist diagnosed the patient with pain in her right ankle and joints and localized edema. He told the patient to ice her ankle, rest and elevate it, and to wrap it for support with an Ace bandage when she exercises.

For the ICD-10 codes, you would report the following:

• M25.571 (Pain in right ankle and joints of right foot)
• R60.0 (Localized edema).

Finally, Put This All Together

In summary, for this encounter, you would report the following codes:

• 73610 (Radiologic examination, ankle; complete, minimum of 3 views).
• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity...).
• M25.571 (Pain in right ankle and joints of right foot)
• R60.0 (Localized edema).