Find information on left ankle sprain diagnosis, including clinical documentation, ICD-10 codes (S93.401A, S93.402A, S93.409A), medical coding, and treatment. Learn about accurate healthcare documentation for a left ankle sprain, covering laterality, severity, and associated injuries. This resource offers guidance for healthcare professionals on properly documenting and coding a left ankle sprain for optimal reimbursement and patient care. Explore details on diagnosis codes, medical necessity, and best practices in clinical documentation for left ankle sprains.
Also known as
Sprain of ankle
Covers sprains and strains of the left ankle.
Injuries to the head, neck, and thorax
Includes a wider range of injuries, encompassing ankle sprains.
Pain in left ankle and foot
May be used if pain is the primary presenting symptom.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the left ankle sprain initial encounter?
Yes
Ligament tear documented?
No
Subsequent encounter for fracture?
When to use each related code
| Description |
|---|
| Left Ankle Sprain |
| Left Ankle Fracture |
| Left Ankle Soft Tissue Injury |
Coding lacks left ankle specificity, potentially leading to incorrect claims and denials. Use S93.402A for accurate coding.
Documentation lacks details on sprain severity (grade 1, 2, or 3) impacting reimbursement and quality metrics.
Missing documentation on the cause of the sprain (e.g., sports injury) makes it difficult to assess injury mechanism and plan appropriate treatment.
Patient presents with complaints of left ankle pain and swelling following an inversion injury while (playing basketball, walking on uneven ground, etc. - specify mechanism of injury). Onset of symptoms occurred (timeframe) ago. Patient reports (mild, moderate, severe) pain localized to the lateral aspect of the left ankle, exacerbated by weight-bearing and palpation. Denies numbness, tingling, or coldness in the foot. Patient reports no prior history of ankle injuries. Physical examination reveals edema and ecchymosis around the left lateral malleolus. Tenderness is noted over the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL). Range of motion is limited due to pain, with decreased plantarflexion and inversion. Neurovascular assessment of the left foot is intact with palpable dorsalis pedis and posterior tibial pulses. Negative anterior drawer test and talar tilt test suggest a grade (I, II, III - specify grade) left ankle sprain. Differential diagnoses include ankle fracture, peroneal tendon injury, and syndesmotic sprain. Radiographic imaging (X-ray, MRI - specify if performed and results) was (obtained, not obtained) to rule out fracture. Diagnosis of left ankle sprain is confirmed. Treatment plan includes RICE (Rest, Ice, Compression, Elevation), NSAIDs for pain management, and referral to physical therapy for rehabilitation exercises to improve range of motion, strength, and proprioception. Patient education provided regarding activity modification, weight-bearing precautions, and follow-up care. Follow-up appointment scheduled in (timeframe) to assess progress and adjust treatment plan as needed. ICD-10 code: (S13.401A, S13.401D, S13.402A, S13.402D, etc. - specify laterality and stage of healing) CPT codes may include (99213, 99214, etc. - specify based on evaluation and management services).