This article has been updated to reflect the FY 2023 ICD-10-CM coding guidelines.
A new patient presents for an initial office visit with complaints of moderate pain and swelling of the right ankle. The physician performs a history and examination and documents it in the medical record. The patient is diagnosed with a sprain of the anterior talofibular ligament (ATFL) of the right ankle. The medical decision-making (MDM) is of low complexity, and the total time spent with the patient was 30 minutes.
Report for the E/M visit and the diagnosis.
A. 99212, S93.431A
B. 99202, S93.401A
C. 99214, S93.431A
D. 99203, S93.491A
D. 99203, S93.491A
This is a new patient seeing the physician in the office for the first time. The MDM is low, and the time spent on the date of the encounter was 30 minutes.
Before we select our E/M code, let me give you a quick update on the changes that took effect on January 1, 2021:
The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) implemented some major revisions for Office or Other Outpatient Services E/M codes 99202-99205 and 99213-99215. CPT code 99201 was eliminated.
The history and physical examination portion is no longer a key component as it relates to code selection. The E/M guidelines state that the physician or other qualified healthcare professional performs a “medically appropriate” history and/or examination. This means they determine the nature and extent of the history or exam based on the specific service.
Code selection is based on the medical decision-making (MDM) component, or total time spent.
For more information on the E/M changes, refer to the document provided by the AMA.
Locate and Verify
To locate the correct E/M code, we can look in the CPT coding manual Index under Outpatient services/ new patient, 99201-99205.
In the Tabular, the correct code can be verified as:
99203, Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making.
When using time for code selection, 30-44 minutes of total time is spent on the date of encounter. That is typical for a low MDM.
In this scenario, the E/M code (99203) would be the same whether we were using time (30 minutes) or medical decision-making (low) to select our code.
In ICD-10, sprains are categorized according to the anatomical location and episode of care. Ankle sprains can be found in Chapter 19 of the coding manual under Injuries to the ankle and foot (S90-S99), and S93, Dislocation and sprain of joints and ligaments at ankle, foot, and toe level.
Locate and Verify
To locate the diagnosis code in ICD-10-CM, look in the Index under Sprain (joint) (ligament)/ ankle/specified ligament NEC. We are referred to S93.49-.
In the Tabular, S93.49 can be verified as Sprain of other ligament of ankle.
However, according to the guidelines, S93.49 is not a valid code. It requires a 7th character. And in this case, the patient is being seen for the first time and receiving active treatment for the sprain. Therefore, “A” should be appended to S93.491 to show it is an initial encounter. This makes our code:
S93.491A, Sprain of other ligament of right ankle, initial encounter
The coding guidelines tell us that S93.49 (Sprain of other ligament of ankle) also applies to:
- Sprain of internal collateral ligament; and
- Sprain of talofibular ligament
If the patient was being seen for a subsequent encounter after having had completed active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase, the 7th character “D” would be added to the code rather than “A”.
If the patient was being seen for a complication or a condition that arose directly from a condition, the 7th character “S” would be used rather than “A” or “D” to show it was a sequela or late effect.
Note: The 6th digit “1” indicates it is the right ankle.
Other important points to note, according to the coding guidelines, include:
- If the patient has an injury of Achilles tendon (S86.0-), that too should be reported (as per the Excludes2 note at S93.4).
- If any associated open wound exists, it should also be reported (as indicated at S93).
- If a strain of muscle and tendon of ankle and foot also exists, S96.- should be reported. (Excludes2 note at S93).
- Secondary code(s) from Chapter 20, External causes of morbidity, should be used if applicable (as per the Chapter 19 guidelines).
Always make sure to review all the coding guidelines before selecting the appropriate code.
Be careful not to confuse a sprain with a strain.
- A sprain is a traumatic injury to a joint involving the ligaments.
- A strain is an injury involving the tendon or muscle.
I talked about this in a previous post.
A, B, and C are incorrect.
A. 99212, S93.431A. CPT code 99212 is an office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter.
S93.431A is for sprain of tibiofibular ligament of right ankle, initial encounter.
B. 99202, S93.401A. CPT code 99202 is an office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision-making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.
S93.401A is for a sprain of unspecified ligament of right ankle, initial encounter.
C. 99214, S93.431A. CPT code 99214 is for an office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision-making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.
S93.431A: As stated above, S93.431A relates to a sprain of the tibiofibular ligament.
What is an Ankle Sprain?
An ankle sprain can occur when it is twisted. The ankle has ligaments that give it support and can get stretched and torn.
According to Stanford Health Care, the most common and serious ankle ligament tears are those in the:
- anterior talofibular ligament (ATFL)
- calcaneofibular ligament (CFL)
- Deltoid ligament complex
The deltoid ligament complex is made up of the anterior tibiotalar ligament, tibiocalcaneal ligament, posterior tibiotalar ligament, and the tibionavicular ligament).
When a significant injury occurs in these primary ligaments, the ankle joint becomes unstable, and pain and dysfunction occur.
Symptoms: Pain and swelling are common.
Cause: Ligament tears in the ankle are the more severe types of ankle sprains and often are due to auto accidents, falls, sports, and ankle dislocations. They can also occur in combination with ankle fractures.
Diagnosis: These injuries are diagnosed based on a physical examination of each ligament, and an MRI is done.
Treatment: Treatment of an ankle sprain usually starts with the RICE approach. RICE stands for rest, ice, compression, and elevation. Once the pain and swelling decrease, physical therapy can help (unless a fracture is present) and is based on the specific ligament injured and the extent of the injury. Surgical reconstruction (replacement) may be needed if the ligament does not heal properly.
The amount of time it takes for an ankle sprain to heal can vary from several weeks to several months. Often, the worse the pain and swelling, the more severe the sprain, and the longer it takes to heal.
How Did You Do?
Did you get the right answer to the challenge? If you scored 100%, way to go!
If not, keep working. You’ll get there because when pigs fly doesn’t matter to your success in medical coding!
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