tci ED Coding & Reimbursement Alert - 2011 Issue 7

You Be the Coder: Choosing Codes on Complex Scenarios

Question: A 36 year old patient presents to the ED with pain and inability to ambulate due to pain in his right lower extremity after a fall. The ED physician notes swelling and ecchymoses just above the patient's right ankle during a detailed exam (notes indicate a detailed history as well). He orders the patient to be medicated with intravenous Dilaudid and orders an x-ray of the ankle and tibia-fibula. The x-ray shows a moderately angulated fracture of the distal portion of the tibial shaft. After the patient receives moderate sedation, the physician manipulates the fracture and re-aligns the...

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