Question

60 year-old patient sustained a comminuted left calcaneal fracture after falling from a ladder. Initial ED treatment consisted of diagnostic radiology studies and surgical ORIF was performed 9 days later. The patient now presents to the orthopedic clinic for evaluation and cast change. The fracture is healing normally. What ICD-10-CM code(s) is/are reported?

a. S92.002D, W11.XXXD
b. S92.002D
c. S92.002A
d. S92.002A, W11.XXXA

Answer 1

The ICD-10-CM code that should be reported for the patient with a comminuted left calcaneal fracture is S92.002D.

Step-by-step explanation:

The ICD-10-CM code that should be reported for the patient with a comminuted left calcaneal fracture is S92.002D.

ICD-10-CM code S92.002D represents a closed fracture of the calcaneus with dislocation, subsequent encounter.

In this case, the fracture was initially treated in the emergency department (ED), and surgical open reduction internal fixation (ORIF) was performed 9 days later. The patient is now presenting for evaluation and cast change, and the fracture is healing normally.

Therefore, the appropriate ICD-10-CM code to report is S92.002D, which captures the specific details of the condition and the encounter.

The correct ICD-10-CM codes to report for the 60-year-old patient who sustained a comminuted left calcaneal fracture after a fall and underwent surgical ORIF (Open Reduction and Internal Fixation) would be S92.002D for the comminuted calcaneal fracture, subsequent encounter for fracture with routine healing, and W11.XXXD for the fall from the ladder, subsequent encounter.