D. 99203, S93.491A
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, 99203 can be verified as an office visit for the evaluation and management of a new patient, requiring a detailed history, detailed examination, and a medical decision making of low complexity. The documentation supports this code. The visit took 30 minutes, which is typical for this level of E/M.
The full description for CPT code 99203 is:
Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.
In ICD-10, sprains are categorized according to the anatomical location and episode of care. Ankle sprains can be found in Chapter 13 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.
To locate the diagnosis code in ICD-10-CM, look in the Index under Sprain (joint) (ligament), ankle, talofibular ligament – see Sprain, 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.
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.
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
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 more in a previous post here.
A, B, and C are incorrect.
A. 99242, S93.431A:
CPT code 99242 is an office consultation for a new or established patient, and the key components that must be met are an expanded problem focused history and examination, and a straightforward medical decision making. Time spent with patient and/or family is typically 30 minutes.
S93.431A is for sprain of tibiofibular ligament of right ankle, initial encounter.
B. 99213 x 2, S93.401A
CPT code 99213 is for an office visit for the E/M of an established patient and must meet 2 of these 3 components: an expanded problem focused history, expanded problem focused examination, and a medical decision making of low complexity. Time spent with patient and/or family is typically 15 minutes.
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 E/M of an established patient and must meet 2 of these 3 components: an expanded problem focused history, an expanded problem focused examination, and a medical decision making of low complexity. Time spent with patient and/or family is typically 25 minutes.
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 occurs.
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. If the ligament does not heal properly, surgical reconstruction (replacement) may be needed.
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.
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