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Office Visit for an Ankle Sprain

office visit for an ankle sprain
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This article has been updated to reflect the FY 2023 ICD-10-CM coding guidelines.

Coding Challenge

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


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