Find information on sprained ankle diagnosis, including clinical documentation, medical coding, ICD-10 codes for ankle sprain, treatment, and rehabilitation. Learn about lateral ankle sprain, syndesmotic sprain, and other ankle injuries. This resource covers proper healthcare documentation for ankle sprains and relevant medical coding terminology for accurate billing and insurance claims. Explore details on ankle sprain diagnosis codes, symptoms, and best practices for healthcare professionals.
Also known as
Sprain of ankle
Injury to ankle ligaments causing pain and swelling.
Other injuries to the ankle and foot
Includes various ankle and foot injuries, excluding fractures.
Injury, poisoning and certain other
Encompasses injuries, poisonings, and external causes.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the ankle sprain specified as initial encounter?
Yes
Right ankle?
No
Subsequent encounter?
When to use each related code
| Description |
|---|
| Ankle sprain |
| Ankle strain |
| Ankle fracture |
Missing documentation of right or left ankle sprain leads to unspecified codes, impacting reimbursement and data accuracy. Medical coding and CDI should query for laterality.
Inaccurate coding of sprain severity (mild, moderate, severe) based on exam findings affects healthcare compliance and appropriate resource allocation. CDI should review documentation for proper severity coding.
Failure to code associated injuries (fracture, ligament tear) with the ankle sprain leads to underreporting of complexity for medical coding and audit purposes. CDI should ensure accurate capture of all injuries.
Patient presents with complaints consistent with an ankle sprain. Onset of symptoms occurred on [Date of injury] during [Mechanism of injury - e.g., sports activity, twisting while walking, fall]. Patient reports [Symptom - e.g., pain, swelling, instability] in the [Location - e.g., lateral, medial, anterior] aspect of the [Affected - e.g., right, left] ankle. Pain is characterized as [Character of pain - e.g., sharp, dull, aching, throbbing] and is [Severity of pain - e.g., mild, moderate, severe] in intensity, exacerbated by [Exacerbating factors - e.g., weight-bearing, palpation, range of motion] and alleviated by [Alleviating factors - e.g., rest, ice, elevation]. Physical examination reveals [Objective findings - e.g., edema, ecchymosis, tenderness to palpation, limited range of motion, instability]. Ottawa Ankle Rules were assessed, and [Result of Ottawa Ankle Rules - e.g., radiographs were indicated, radiographs were not indicated]. [Imaging results, if applicable - e.g., Radiographs of the ankle were negative for fracture]. Assessment: Ankle sprain, [Laterality - e.g., right, left], [Grade of sprain if determined - e.g., Grade I, Grade II, Grade III]. Differential diagnosis includes fracture, tendon injury, and ligament tear. Plan: RICE therapy (rest, ice, compression, elevation) is recommended. Patient is instructed on ankle sprain treatment, including pain management with [Pain medication prescribed - e.g., ibuprofen, acetaminophen]. [Assistive device if applicable - e.g., Crutches, ankle brace] are prescribed. Follow-up appointment scheduled in [Duration - e.g., one week, two weeks] to assess healing progress and discuss physical therapy referral if necessary. Patient education provided regarding activity modification, weight-bearing precautions, and potential complications. ICD-10 code: [Appropriate ICD-10 code, e.g., S93.401A, S93.402A].