Audit Case Unit Question & Answer Guide (With Explanation)

This question focuses on applying theory to practical scenarios.

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Original Question

Audit case MC285-Unit 6-PO Case Study 2 Verify the codes given: CPT: 99211 ICD-10-CM: S93.402D, W10.1XXA, Y99.8 Are the provided codes correct or incorrect? If they are incorrect codes, please provide the correct codes. MC285-Unit 6-PO Case Study #2 Office Visit Chief Complaint: left foot and ankle pain History: the patient is a 16-year-old male seen today after falling off a curb and twisting his left ankle. He was walking his dog in his neighborhood when suddenly, the dog began to run, pulling the patient from the Sidewalk and off the curb, causing the patient to fall while trying to regain control. He is usually a patient of Dr. Sunshine, who is out-of- town this week and seen by a physician within the same clinic and specialty. The patient states he has pain surrounding the entire foot and ankle. He seems to be unable or unwilling to bear weight on the left side. Exam: ankle and foot were examined. The foot is warm to touch. Some swelling and bruising noted around the lateral aspect of the ankle. X-ray is negative for fracture. Impression: Sprained left ankle. (MDM is straightforward) Plan: elevation; ice to the affected area. Weightbearing a tolerated. Return for follow-up prn. CPT: • 99211 ICD-10-CM: • S93.402D • W10.1XXA • Y99.8

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