Quiz #2: Fall at the Playground

Fractures require a lot of aftercare coding. However, unlike other types of aftercare which carry their own set of codes, fracture coding uses the 7th character in the sequence to define the episode of care for the fracture. They also characterize the type of fracture, the degree of damage, and whether or not surrounding tissue or blood vessels were affected by the injury.

Date: June 22, XXXX
Chief Complaint: Left tibia fracture 
HPI: Patient is an 11-year-old male whom we saw on 06/07/XX. He was injured when he jumped from the swings at school. He sustained a Salter-Harris II fracture of the distal tibia. He is currently non-weight bearing in a short-leg cast and his mother states he has been compliant with his activity modifications.
Exam: He is intact to sensation. His capillary refill of the toes remains stable. There is no skin breakdown at the proximal or distal aspect of the intact cast.
Ancillary Studies: AP and mortise views radiographs of the left ankle were ordered and obtained in our office today. These show good alignment and positioning of the fracture. Physis is stable.
Impression: Left distal tibia fracture
Plan: Continue to maintain non-weight bearing status with short-cast. Return for reassessment in 2 weeks.
What is the first listed ICD-10-CM code for this encounter?
S89.122D
Correct: Documentation states the patient is back for a follow-up for his Salter-Harris II fracture of the left distal tibia with routine healing.
S89.022A
Incorrect: S89.022A is the code the proximal (upper end) of the tibia. The 7th character indicates this is an initial visit.Documentation indicates the patient is back for a subsequent visit for his Salter-Harris II fracture of the left distal (lower end) tibia with routine healing. 
S89.302D
Incorrect: Higher specificity is reached with the documentation of a Salter-Harris II type fracture.
S89.102A
Incorrect: Higher specificity is reached with the documentation of a Salter-Harris II type fracture. Additionally, it is also indicated this is the patient’s subsequent encounter, not initial.
What CPT codes will be used for this encounter?
99212-25, 73600
Correct: The doctor performed a problem focused history and an expanded problem focused exam with a straight-forward MDM (99212). He receives one point because he orders 2 view x-rays (73600) and interprets the results. Since he is billing for the interpretation, he does not receive 2 additional points towards the MDM. Modifier 25 is added to indicate a significant and separately identifiable E/M was performed with another service.
99213-25, 73610
Incorrect: The doctor performed a problem focused history and an expanded problem focused exam with a straight-forward MDM (99212). He receives one point because he orders 2 view x-rays (73600) and interprets the results. Since he is billing for the interpretation, he does not receive 2 additional points towards the MDM.
99214-25, 73600
Incorrect: The doctor performed a problem focused history and an expanded problem focused exam with a straight-forward MDM (99212). He receives one point because he orders 2 view x-rays (73600) and interprets the results. Since he is billing for the interpretation, he does not receive 2 additional points towards the MDM.
99212-25, 73610
Incorrect: The doctor performed a problem focused history and an expanded problem focused exam with a straight-forward MDM (99212). He receives one point because he orders 2 view x-rays (73600) and interprets the results. Since he is billing for the interpretation, he does not receive 2 additional points towards the MDM.

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