Question

A patient comes in for evaluation of a right ankle injury after playing a game of basketball and falling after turning his ankle. He is in extraordinary pain and the physician has ordered an x-ray using the diagnosis code of S99.911A for unspecified right ankle injury, initial encounter. The x-ray comes back with a finding of a displaced fracture of medial malleolus of the right tibia. At the follow up visit with the patient, the physician continues to use the S99.911A ICD-10 code for the diagnosis and gets a denial from the insurance when he attempts to get an MRI of the fractured ankle. Do you think this would have been the result if the physician had used S82.51 (displaced fracture of medial malleolus of right tibia) instead? Why or why not? Explain. How does this apply to the concept of medical necessity discussed earlier in the course?

Answer 1

   ICD Codes and Insurance claiming process

ICD codes are the one which identifies medical diagnoses of the patient and help in the process of insurance claiming from the insurance companies.

CMS i.e. Centre for Medicare and Medicaid Services of U.S., provides larger information about ICD Codes.

ICD (International classification of Diseases) , was evolved actually by WHO which are initially ICD 1 changed to ICD 9 and subsequently currently using ICD 10.

In the above scenario we have a ICD 10 code specified I.e.

S99.911A which is a code for unspecified right ankle injury.

  This ICD 10 code cannot provide insurance claims, as this is only injury , and also unspecified one.

Always any injury leads to wither fracture, laceration, subluxation, confusion and abrasion etc.

Insurance cannot be claimed or insurance denied because

All the details of injury and incidence are specifically taken in to consideration while coding such as

What is the type of fracture?

Where it happened?

When it happened and the type of injury happened?

Here the X Ray clearly shows that there was a displaced fracture of medial malleous of right tibia.

So physician should have been changed the code to S82.51 where the patient would not have denied for claiming of MRI.

Hope this answer best helps you.