An 8-year-old established patient is seen for an ankle injury caused by a fall on a trampoline in his backyard. A detailed history and expanded problem-focused examination are performed and documented. A 3-view x-ray taken in the office with interpretation and report by the physician showed a fracture of the distal left tibia. The physician applied a non-pneumatic Controlled Ankle Motion (CAM) Walker boot to stabilize and protect the fracture and referred him to see an orthopedist in one week. The diagnosis is fracture of the distal tibia. What codes may be reported for this encounter?

Because the physician placed a splint as a protective measure and the patient is being referred to an orthopedic physician, we know that global fracture care was not provided. When a physician or other qualified health care professional fabricates the initial splint or cast as a protective measure for a fracture pending restorative treatment,...

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