ICD 10 Codes For Ankle Sprain
ICD-10 Knows We Have Two Ankles :-)
Since October 1st, 2015, gone are the days when one could use general diagnostic codes like 845.09, which in ICD-9-CM stands for "Other sprains and strains of ankle". In ICD-10-CM, you have to be specific not only in terms of which ankle your patient sprained, but also whether the encounter you are conding is an initial, subsequent or sequela. I know, it is a big change. But if you want to get paid, you better code it right, so here is a quick rundown on how to do it.
Ankle Sprain Injury Example
Suppose you see a patient for the first time for a right ankle sprain. You don't suspect any fracture, you give them instructions to apply ice, write for an NSAID, and you tell them to return in 2 weeks if not improved.
You start to build your ICD-10 code for this encounter with S93.4, which stands for Sprain of ankle.
Remember, though, that this is not a billable code. You have to specify laterality, so your next stop is at S93.401, which codes Sprain of unspecified ligament of right ankle. This is better, but we are still missing something. Guessed it? You are right, we need to specify that this is an initial encounter. To do that, we append the code with the letter "A", which in ICD-10-CM stands for initial encounter. So your final, billable ICD-10 code to use for this patient is S93.401A.
Of course, you could (and should) make your life a lot easier by entering the relevant keywords for this issue (i.e. right ankle sprain initial encounter) into the ICD-10-CM search tool on our site and get the billable code right away.
Finally, if this patient shows up for a follow-up for the same problem, you would use ICD-10 code S93.401D for a "Sprain of unspecified ligament of right ankle, subsequent encounter", and if they end up having long-term issues from the ankle injury, you can make use of code S93.401S, which specifies "Sprain of unspecified ligament of right ankle, sequela".
Nothing too complicated, once you get the hang of it :-).