Question

Gladys Swain slipped and fell from a sidewalk curb and twisted her right ankle. Because of the severe pain she was suffering and the inability to bear weight on the foot, she sought treatment at her neighborhood hospital emergency department. The treating physicians were fairly confident that Ms. Swain had an ankle injury. The physician completed a problem-focused history regarding the injury and a problem-focused physical examination of her right foot and ankle. The MDM complexity was straight forward. The patient was immediately sent to the radiology department for an x-ray. A two-view x-ray of the right ankle was completed. The radiologist confirmed a simple non-displaced closed fracture of the medial malleolus. The patient then returned to the emergency department, where the physician immobilized the ankle. The patient was referred to an orthopedic surgeon. Code the emergency department service and the radiology service.