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S93.401A
ICD-10-CM
Right Ankle Sprain

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

Right Ankle Ligament Injury
Right Ankle Twist
Ankle Ligament Injury
+3 more

Diagnosis Snapshot

Key Facts
  • Definition : Stretching or tearing of ligaments in the right ankle.
  • Clinical Signs : Pain, swelling, bruising, limited range of motion, instability.
  • Common Settings : Sports injuries, falls, awkward foot placement.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC S93.401A Coding
S93.4

Sprain of right ankle

Injury to the ligaments of the right ankle joint.

S93

Other injuries to the ankle and foot

Includes sprains and other injuries to the ankle and foot, excluding fractures.

S00-T98

Injuries, poisonings and external causes

Encompasses various injuries, including those to the musculoskeletal system.

Code-Specific Guidance

Decision Tree for

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?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Right ankle sprain
Left ankle sprain
Ankle instability

Documentation Best Practices

Documentation Checklist
  • Laterality (right ankle)
  • Mechanism of injury
  • Severity (grade 1, 2, or 3)
  • Clinical findings (e.g., swelling, ecchymosis)
  • Treatment plan

Coding and Audit Risks

Common Risks
  • Laterality Unspecified

    Coding right ankle sprain without specifying laterality (right) can lead to claim denials and inaccurate data reporting. Use S93.401A.

  • Incomplete Documentation

    Lack of specific details about the sprain (e.g., grade, ligaments involved) hinders accurate code assignment and reimbursement. CDI crucial.

  • Unspecified Cause

    Failing to document the cause of the right ankle sprain (e.g., sports injury, fall) can impact injury-related statistics and compliance audits.

Mitigation Tips

Best Practices
  • RICE therapy promptly: Rest, Ice, Compression, Elevation
  • ICD-10 S93.401A, precise laterality documentation crucial for CDI
  • Document sprain grade (I-III) and ligament(s) involved for accurate coding
  • Assess Ottawa Ankle Rules for fracture risk, optimize patient safety and compliance
  • Detailed HPI and exam findings essential for compliant billing and appropriate care

Clinical Decision Support

Checklist
  • 1. Palpate for tenderness (lateral ligaments)
  • 2. Assess ROM and instability
  • 3. Ottawa Ankle Rules applied
  • 4. Evaluate for fracture (X-ray if needed)
  • 5. Document sprain grade (I, II, or III)

Reimbursement and Quality Metrics

Impact Summary
  • Right Ankle Sprain: Reimbursement and Quality Metrics Impact Summary
  • ICD-10: S93.401A (Initial encounter), S93.409A (Subsequent)
  • CPT: Evaluation and Management codes (e.g., 99281-99285), Procedure codes (e.g., 27650 for application of cast/splint)
  • Impact 1: Accurate coding maximizes reimbursement for ankle sprain care.
  • Impact 2: Coding errors can lead to claim denials and reduced revenue.
  • Impact 3: Proper documentation supports quality reporting for ankle injury management.
  • Impact 4: Optimize medical billing for sprains to improve financial performance.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Lateral ankle sprain: use S93.401
  • Medial ankle sprain: use S93.402
  • Document ligament tear specificity
  • Grade sprain (I, II, III)
  • Initial vs. subsequent encounter

Documentation Templates

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.
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