Question

Mrs. Kelly had an appointment to see the doctor for a persistent low- grade fever. During the visit she mentioned that she had twisted her ankle a week or so ago and that it still hurt when she put weight on it. The doctor took -rays and found that there was a stress fracture. He gave her a post-op shoe to wear to provide more support and reduce her pain. When coding this patient’s visithe used fever for the diagnosis code, and he used x-rays and a post-op shoe for the procedure codes. What error did the doctor make when coding?

Answer 1

Mrs. Kelly was not treated for her persistent low-grade fever. Which could have been due to a week long pain from the twisted ankle. However the primary concern for which Mrs. Kelly was treated was the twisted ankle and not the fever.

X-Rays were taken to find out the reason for pain in the ankle, and after Mrs.Kelly was diagnosed with a stress fracture a post-op-shoe was given to wear to provide support and reduce pain.

Thus while coding, Twisted ankle or stress fracture should have been the diagnosis code, and corresponding to it, x-rays and a post-op-shoe should be used for the procedure codes.

The diagnosis code used by the doctor was wrong, while the procedure codes were correct.