CPT Knowledgebase - Apr 7, 2025

A 9-year-old established patient was seen in the office after falling off a bed and twisting their right ankle. The patient had pain around their ankle and was unable or unwilling to bear weight on the right side. The right ankle was examined with noted pain around the ankle, and an X ray was ordered and performed in the office. The X ray was reviewed by the treating physician or other qualified health care professional (QHP) and was negative for a fracture; therefore, it was determined that the patient had a sprained right ankle. The patient was instructed to elevate the right ankle, ice the affected area, perform weight-bearing activities as tolerated, and return for a follow-up appointment as needed. What would be the appropriate E/M code to report for this scenario?

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