Ankle Fracture with Sprain

LLRodgers

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Hello,

Just wanted to see what is the proper way to code the following:

Patient fractures medical malleolus and has an ankle sprain (both occurred at the same time, same ankle).

Would code everything under the fracture care or would you code the fracture under a fracture care code and the
Sprain with a straight E/M Code?

Thank you,

LLR
 
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Since the ankle injury is the only thing being treated here, it seems fracture care would be the most appropriate CPT code. Depending on the documentation of what care your doctor is providing. I would not recommend an E/M code for the sprain (that's part of the ankle injury) but if there is something else being evaluated and treated here as well during this visit.......... maybe. It would need to be something distinctly separate from the ankle injury to support an E/M and the Medical Decision Making for the E/M would need to be care and thought process and treatment for that distinctly separate issue- not the ankle. :)
 
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