Find information on left ankle swelling diagnosis, including differential diagnoses, ICD-10 codes (e.g., M79.89, R60.0), clinical documentation tips, and medical coding guidelines. Learn about common causes of unilateral ankle edema, such as trauma, cellulitis, DVT, venous insufficiency, and lymphatic obstruction. Explore relevant healthcare resources for accurate diagnosis and treatment of left ankle swelling.
Also known as
Pain in left ankle and foot
Swelling is often associated with pain in the ankle.
Localized swelling, not elsewhere classified
A general code for swelling when a more specific cause isn't known.
Venous insufficiency (chronic) (peripheral)
Venous issues can cause leg and ankle swelling.
Pain in left ankle and foot
Includes other specified joint derangements of left ankle and foot.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is there known trauma/injury to left ankle?
Yes
Current injury?
No
Systemic disease causing swelling (e.g., heart failure, kidney disease)?
When to use each related code
| Description |
|---|
| Left ankle swelling |
| Left ankle sprain |
| Left ankle fracture |
Coding left ankle swelling with unspecified codes (e.g., R22.2) without proper documentation of etiology leads to lower reimbursement and audit risk. CDI should query for specificity.
Incorrectly coding traumatic swelling (e.g., S90) as a systemic condition (e.g., I84) impacts data integrity and reimbursement. Accurate documentation is crucial for correct coding.
Missing or incorrect laterality (left vs. right) can lead to claim denials and compliance issues. Coders must validate laterality through documentation and imaging reports.
Patient presents with left ankle swelling. Onset of swelling was (duration and onset details e.g., two days ago, gradual onset, sudden onset after inversion injury). Location of swelling is localized to the (specify location e.g., medial malleolus, lateral aspect of the ankle, entire ankle joint). Character of swelling is described as (e.g., pitting, non-pitting, tense, erythematous, warm). Patient reports (presence or absence of) pain in the left ankle. Pain quality is described as (e.g., sharp, dull, aching, throbbing) with a severity of (scale of 0-10). Aggravating factors include (e.g., weight-bearing, ambulation, palpation). Alleviating factors include (e.g., rest, elevation, ice). Associated symptoms include (e.g., limited range of motion, ecchymosis, numbness, tingling, fever, chills). Patient denies (any pertinent negatives e.g., trauma, recent surgery, insect bites). Medical history significant for (relevant medical history e.g., diabetes, hypertension, prior ankle injury, arthritis). Surgical history includes (relevant surgical history e.g., prior ankle surgery). Medications include (list current medications). Allergies include (list allergies). Physical examination reveals (objective findings e.g., edema, erythema, warmth, tenderness to palpation, limited range of motion, palpable pulses). Differential diagnosis includes (list potential diagnoses e.g., sprain, strain, fracture, cellulitis, deep vein thrombosis, arthritis). Assessment: Left ankle swelling, likely secondary to (presumptive diagnosis). Plan: (Outline plan of care e.g., obtain ankle radiographs, prescribe NSAIDs, recommend RICE therapy rest, ice, compression, elevation, referral to orthopedics, follow-up in one week). Patient education provided regarding (e.g., RICE protocol, medication instructions, signs and symptoms to watch for). ICD-10 code: (add appropriate code based on presumptive diagnosis).