“I saw a patient on March 20, 2020 with a new, mildly displaced 3rd metatarsal fracture (S92.332A). I have been following him since then and have billed Anthem Blue Cross with ICD10 S92.331D and have gotten reimbursed. The last visit I had with the patient was August 17, 2020 and billed Anthem Blue Cross for S92.332S. The claim was denied as Missing/incomplete/invalid principal diagnosis. Isn’t S92.332S a valid primary diagnosis code?”
So, a patient had a mildly displaced fracture of the third metatarsal on the left foot. It was initially treated and the ICD-10-CM code that was used on the initial treatment encounter for this patient was S92.332A which is defined as: Displaced fracture of 3rd Metatarsal bone, left foot, initial encounter and treatment. It appears that through the follow up period of this third metatarsal fracture of the left foot, claims were submitted for subsequent treatment and were reimbursed using ICD-10-CM code S92.332D which is defined as: Displaced fracture of 3rd Metatarsal bone, left foot subsequent encounter for fracture with routine healing. I am assuming that S92.331D was a typo as the correct ICD-10-CM code would be S92.332D which is defined as: Displaced fracture of 3rd Metatarsal bone, left foot subsequent encounter for fracture with routine healing.
The initial date of treatment for the metatarsal fracture was March 20, 2020. The final encounter with this patient for the same problem was August 17, 2020. On this final date of service the ICD-10-CM code that was used was S92.332S which is defined as: Displaced fracture of third metatarsal bone, left foot, sequela. The reason that the encounter for this date of service was not reimbursed is due to the fact that S92.332S is not a valid primary diagnosis code. The definition of sequela is the following: a condition which is the consequence of a previous disease or injury. Based upon this premise, there needed to be a “new” problem that resulted from or was caused by the previous injury, the displaced fracture of the metatarsal of the left foot. If this was indeed the case, the primary ICD-10-CM code would represent or indicate the “new” condition that was caused by the metatarsal fracture. The secondary or supportive ICD-10-CM code would be S92.332S. If there was not a condition that resulted from the original injury, then the ICD-10- CM code that should have been used on the final encounter with this patient should have been S92.332D, Displaced fracture of 3rd Metatarsal bone, left foot subsequent encounter for fracture with routine healing.
This is my opinion.
Michael G. Warshaw
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