AHA Coding Clinic® for ICD-9 - 2001 Fourth Quarter
Ask the Editor
A patient comes into the emergency department after he injured his ankle while running. An x-ray of the ankle was taken and read by the emergency department physician. The patient was discharged home with the diagnosis of ankle sprain, rule out ankle fracture. Upon review of the x-rays the next morning, the radiologist documents "hairline fracture of the lateral malleolus." What code should the hospital emergency department assign? ...
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Article Overview
This article discusses a hospital emergency department coding scenario involving an ankle injury, later imaging review, and diagnosis assignment based on information available at the time of reporting. It is aimed at coders and revenue cycle staff who need to understand how late-arriving test interpretations can affect documentation and code specificity. The discussion is framed as an editor response to a practical hospital coding question.
Why This Topic Matters
It helps readers understand how a hospital may reflect newly available diagnostic information in the reported diagnosis for an emergency department encounter.
What You Will Learn
- How hospital coding may reflect information available at the time of code assignment
- How later diagnostic interpretation can affect diagnosis specificity
- How an emergency department encounter may be coded when imaging results are reviewed after the visit
- How to think about coding questions involving fracture evaluation after an injury
Who Should Read This
- Medical coders
- Hospital billing staff
- Revenue cycle professionals
- Emergency department coding staff
Codes Discussed
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