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Office Visit for an Ankle Sprain

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

Answer:

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