Experiencing pain in toe? This guide covers clinical documentation and medical coding for toe pain diagnosis, including causes like hallux rigidus, gout, sesamoiditis, broken toe, ingrown toenail, and Morton's neuroma. Learn about ICD-10 codes, CPT codes, differential diagnosis, and proper medical terminology for accurate healthcare records and billing related to great toe pain, small toe pain, and other toe joint pain conditions. Find information on diagnosis, treatment, and resources for patients and healthcare professionals dealing with toe pain.
Also known as
Pain in limb
Includes pain localized to toe(s).
Nerve root and plexus disorders
May cause referred pain to the toe.
Pain in joint
Includes pain specifically in toe joints.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the toe pain due to trauma/injury?
Yes
Is there a fracture?
No
Ingrown toenail?
When to use each related code
| Description |
|---|
| Pain in toe |
| Ingrown toenail |
| Toe fracture |
Coding pain in toe without specifying laterality (right, left) or specific toe leads to claim denials and inaccurate data.
Failing to code the underlying cause of traumatic toe pain (e.g., fracture) results in undercoding and lost revenue.
Miscoding gout as unspecified toe pain impacts data integrity and reimbursement for appropriate gout management.
Patient presents with complaint of toe pain. Onset, duration, location, character, aggravating and alleviating factors, and radiation of pain were assessed. Differential diagnoses considered include hallux valgus, hammer toe, Morton's neuroma, ingrown toenail, fracture, gout, arthritis, sesamoiditis, tendinitis, and infection. Physical examination included palpation, range of motion assessment, and evaluation for edema, erythema, warmth, and deformity. Neurovascular status of the affected toe and foot was assessed. Patient's pain is localized to the (specify toe: e.g., great toe, second toe, etc.) and is described as (specify character: e.g., sharp, throbbing, dull, aching). The pain is (specify onset: e.g., acute, chronic, insidious) and (specify duration: e.g., constant, intermittent). Aggravating factors include (list aggravating factors: e.g., weight-bearing, certain shoes). Alleviating factors include (list alleviating factors: e.g., rest, elevation). The pain (specify radiation: e.g., radiates to the foot, does not radiate). Physical examination revealed (describe findings: e.g., tenderness to palpation, limited range of motion, edema, erythema). Diagnostic studies (specify studies if ordered or performed: e.g., X-ray, ultrasound) were (describe results: e.g., negative for fracture, positive for osteoarthritis). Assessment: Pain in toe, likely due to (specify most likely diagnosis). Plan: Treatment plan includes (specify treatment: e.g., RICE therapy, NSAIDs, orthotics, referral to podiatry). Patient education provided regarding (specify education: e.g., activity modification, footwear recommendations). Follow-up scheduled in (specify timeframe: e.g., one week, two weeks). ICD-10 code (specify relevant ICD-10 code) and CPT code (specify relevant CPT codes for procedures performed, if applicable) will be assigned.