Wiki Sequela fx with pain

[torl35]

Can someone answer this for me? Patient comes in 18 months after pilon fx (healed). Patient now has pain in that ankle with no OA. Should I code:

M25.572 and Z87.81 or M25.572 and S82.872S

 

[mitchellde]

You would code it as sequela only if the provider documents the current pain as being caused by the fracture.

 

[torl35]

All the Dr. said is that the patient is having pain in left ankle and s/p left pilon fx.

 

[mitchellde]

Without the provider staying that the pain is due to the fracture, you code only the pain.

 

[torl35]

Ok that is what I have been doing just wanted to confirm. thank you