Revenue Cycle Insider

Question: A 30-year-old patient presented to the podiatrist with dorsal left foot pain that had worsened over two weeks. The podiatrist performed a physical examination that revealed point tenderness over the second metatarsal shaft, mild edema, and pain with forefoot loading. The physician ordered anteroposterior (AP), oblique, and lateral X-rays of the left foot. After reviewing the images, the provider ordered an MRI without contrast of the foot. The MRI revealed marrow edema with a nondisplaced stress fracture of the second metatarsal shaft.

Can you help me code this encounter?

Mississippi Subscriber

Answer: Absolutely! Let’s start with the procedures performed. Use 73630 (Radiologic examination, foot; complete, minimum of 3 views) to report the three-view X-rays. Next, you’ll assign 73718 (Magnetic resonance (eg, proton) imaging, lower extremity other than joint; without contrast material(s)) to report the MRI without contrast of the foot. Check with the payer to confirm if it wants you to include a laterality modifier for the procedure codes. If so, you’ll append LT (Left side) to 73630 and 73718 to indicate the X-rays and MRI were performed on the left foot.

Lastly, turn to the ICD-10-CM code book to assign the correct diagnosis code for the patient’s injury. Use M84.375A (Stress fracture, left foot, initial encounter for fracture) to report the stress fracture of the left foot. The 7^th character “A” specifies that the patient is seeking active treatment for their injury.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC