Find information on Right Ankle Sprain diagnosis, including clinical documentation tips, ICD-10 codes (I84.0, I84.1, I84.8, I84.9), medical coding guidelines, and healthcare resources. Learn about right ankle sprain symptoms, treatment, and documentation best practices for accurate medical billing and coding. This resource covers lateral ankle sprain, medial ankle sprain, syndesmotic ankle sprain, and ankle sprain unspecified, supporting comprehensive clinical documentation for healthcare professionals.
Also known as
Sprain of right ankle
Injury to the ligaments of the right ankle joint.
Other injuries to the ankle and foot
Includes sprains and other injuries to the ankle and foot, excluding fractures.
Injuries, poisonings and external causes
Encompasses various injuries, including those to the musculoskeletal system.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the right ankle sprain specified as initial encounter?
Yes
Ligament tear confirmed?
No
Subsequent encounter, routine healing?
When to use each related code
Description |
---|
Right ankle sprain |
Left ankle sprain |
Ankle instability |
Coding right ankle sprain without specifying laterality (right) can lead to claim denials and inaccurate data reporting. Use S93.401A.
Lack of specific details about the sprain (e.g., grade, ligaments involved) hinders accurate code assignment and reimbursement. CDI crucial.
Failing to document the cause of the right ankle sprain (e.g., sports injury, fall) can impact injury-related statistics and compliance audits.
Patient presents with complaints of right ankle pain and swelling following an inversion injury while playing basketball. Onset of symptoms occurred approximately two hours prior to presentation. Patient reports hearing a popping sensation at the time of injury. Physical examination reveals moderate edema and tenderness over the lateral aspect of the right ankle, specifically at the anterior talofibular ligament. Pain is exacerbated with palpation and range of motion, particularly with inversion and plantarflexion. No ecchymosis is currently present. Neurovascular assessment of the right foot is intact, with palpable dorsalis pedis and posterior tibial pulses. Strength and sensation are grossly intact distally. Anterior drawer test and talar tilt test of the right ankle are positive, indicating ligamentous instability. Radiographs of the right ankle were obtained and are negative for fracture or dislocation. Assessment: Right ankle sprain, likely grade II, involving the anterior talofibular ligament. Differential diagnosis includes peroneal tendon injury and ankle fracture, which have been ruled out based on clinical findings and imaging. Plan: RICE therapy (rest, ice, compression, elevation) is recommended. Patient is instructed to use crutches for non-weight bearing ambulation for the next 48-72 hours. Prescribed ibuprofen 600mg every six hours as needed for pain. Follow-up appointment scheduled in one week to assess for improvement and initiate physical therapy for range of motion and strengthening exercises. Patient education provided on ankle sprain treatment, recovery, and prevention strategies. ICD-10 code: S93.401A.