Wiki help with CPT - Ankle sprain from falling off skateboard

[ggparker14]

Ankle sprain from falling off skateboard. X-ray taken. Splint applied. Instructed to use ice and non-weightbearing until better. To use ibuprofen as needed.

Want other opinions on level of care.

Thanks for any help.

 

[jimbo1231]

99283

This is most commonly coded as a 99283 based on treatment and diagnostic. Of course the documentation would have to be there. Also the splinting can be coded separately if done, Medicare, or managed by the provider.

Jim

 

[ptrautner]

Re: CPT question

i would agree with the three depends on if you follow acep or a point system however...i would add a short leg splint for the procedure

 

[FTessaBartels]

Is this the actual note?

Ankle sprain from falling off skateboard. X-ray taken. Splint applied. Instructed to use ice and non-weightbearing until better. To use ibuprofen as needed.

Want other opinions on level of care.

Thanks for any help.

If this is the actual documentation ... vs your synopsis of the documentation ....
You don't have a billable E/M service documented. Depending on for whom you are coding, you might have splint application.

Hope that helps.

F Tessa Bartels, CPC, CEMC