Find information on Right Wrist Sprain diagnosis, including clinical documentation, medical coding, ICD-10 codes, symptoms, treatment, and prognosis. Learn about proper healthcare documentation for a Right Wrist Sprain and relevant medical coding guidelines. This resource provides details on Right Wrist Sprain for healthcare professionals, coders, and patients seeking information on this specific diagnosis. Explore resources related to wrist pain, sprain diagnosis, and differential diagnosis for wrist injuries.
Also known as
Dislocations, sprains and strains of wrist
Covers sprains and strains of wrist and hand joints.
Injuries to the wrist and hand
Includes various injuries like fractures, dislocations, and sprains of the wrist and hand.
Injuries, poisonings and other consequences
Encompasses a wide range of injuries, including those to the wrist.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the right wrist sprain specified as traumatic?
Yes
Is there a dislocation?
No
Code as M79.101 - Pain in right wrist
When to use each related code
Description |
---|
Right Wrist Sprain |
Right Wrist Strain |
Right Wrist Contusion |
Coding lacks right or left wrist designation. Use S63.501A for right wrist sprain, avoiding unspecified S63.509A. Impacts reimbursement and data accuracy.
Documentation lacks detail on sprain grade (mild, moderate, severe) impacting correct ICD-10 and potential undercoding. CDI crucial for accurate capture.
Underlying cause (e.g., fall, sports injury) not documented. Affects coding accuracy, risk adjustment, and compliance with clinical documentation guidelines.
Patient presents with complaints of right wrist pain and swelling following a fall on an outstretched hand. Onset of symptoms occurred approximately two days ago. Patient reports pain is exacerbated by movement and describes it as sharp and aching. Physical examination reveals tenderness to palpation over the lateral aspect of the right wrist, mild edema, and ecchymosis. Range of motion is limited due to pain, particularly with extension and radial deviation. No crepitus or obvious deformity noted. Neurovascular examination of the hand is intact. Given the mechanism of injury, clinical presentation, and physical exam findings, the diagnosis of right wrist sprain is made. Differential diagnoses considered include fracture, tendonitis, and ligament tear. Radiographs of the right wrist were obtained to rule out fracture and are negative for acute bony abnormality. Treatment plan includes RICE therapy (rest, ice, compression, elevation), NSAIDs for pain management, and a right wrist splint for immobilization. Patient education provided regarding activity modification and follow-up care. Follow-up scheduled in one week to assess symptom improvement and discuss potential physical therapy referral if indicated. ICD-10 code S63.501A, right wrist sprain, initial encounter, is assigned.