Mrs. Kelly had an appointment to see the doctor for a persistent lowgrade fever.

Question

Mrs. Kelly had an appointment to see the doctor for a persistent lowgrade 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 xrays and found that there was a stress fracture. He gave her a postop shoe to wear to provide more support and reduce her pain. When coding this patient’s visit, he used fever for the diagnosis code, and he used xrays and a postop shoe for the procedure codes. What error did the doctor make when coding?

Explanation / Answer

The doctor gave diagnosis code for fever (ICD-9-CM coding manual; diagnosis code: 780.60) and procedure code for stress fracture in her ankle (ICD-10-CM Diagnosis Code M84.373 for unspecified ankle). The diagnosis is inconsistent with the procedure.

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