Remember to Use Symptoms When a Fracture Is Ruled out
Question: I have a radiology report for X-rays of a 36-year-old patient complaining of wrist pain. The patient walked outside to get the mail, tripped when stepping off their porch, and landed on their outstretched left wrist. The radiologist captured posteroanterior (PA), lateral, and oblique views of the left wrist. The images revealed there were no fractures and the carpal alignment was maintained. What codes should we assign? North Dakota Subscriber Answer: Let’s start with the procedure. The radiologist captured three X-ray views — PA, lateral, and oblique — of the patient’s left wrist. Assign 73110 (Radiologic examination, wrist; complete, minimum of 3 views) to report this procedure. You’ll also append modifier LT (Left side) to specify that the X-rays were of the left wrist. Next, you’ll turn your attention to the diagnosis codes. Since the radiologist noted there were no fractures, you won’t assign a fracture code. In this case, you’ll assign a symptom code to report what the patient was experiencing at the time of the encounter. Use M25.532 (Pain in left wrist) to report the pain in the left wrist. You can also assign W13.0XXA (Fall from, out of or through balcony, initial encounter) to indicate that the patient fell off the porch. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
