Wiki ICD-10 for old ankle injury


Local Chapter Officer
Shelley, Idaho
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Patient had an ankle injury about 1 year ago from rolling her ankle and now presents with pain and some swelling more recently. Doctor has stated for diagnosis "Lateral ankle sprain with mild residual symptoms"

Do I code this to the S43.401S as a sequela and add the swelling diagnosis also or do I just code to the ankle pain and swelling?

Any help would be appreciated.
Your note says S43. as an ankle sprain, but S43 is for the shoulder region, so I am assuming that is a "typo."
Assuming that there is no new or recent injury to cause the more recent/current increased ankle pain and swelling, then I would relate it back to the original injury, "lateral ankle sprain" and use S93.49 _ S (6th Character 1 for right, 2 for left, your note doesn't say which), and S for Sequela from the original injury. I recommend 5th Character 9 for "Other ligament/s" of the ankle. The most commonly "sprained" ligament of the ankle is the Talo-fibular ligament, which for some bizarre reason in ICD-10 is not listed a "specified" ligament in the Ankle Sprain Code Set, so it has to be allocated to "Other" (i.e. "none of the above").
As for the "swelling" of the ankle, the Alphabetical Index of Diseases refers "Joint Swelling" to Effusion of the joint. Also, "Edema" of the ankle refers to Effusion of the joint. Unfortunately, most residual ankle swelling from previous injury is in the extra-articular soft tissues (edema) and not intra-articular (effusion). Unfortunately, I am not able to resolve this particular dilemma of semantics, so you would have to go with M25.47 _ (6th Character 1 for right, 2 for left).
The ankle "pain" has only one possibility, M25.57 _ (again 6th Character 1 for right, 2 for left), for Ankle Joint Pain, and which doesn't really differentiate acute from chronic pain, which this would be at this time. This could be supplemented with G89.21, Chronic pain from previous trauma, since the patient is being seen for bot "ankle pain" and "swelling."
The Sequencing would be the pain and swelling codes first, and ending/finishing with the Ankle Sprain code with S.

I will be interested to see what others might have to say.

I hope this is helpful.

Respectfully submitted, Alan Pechacek, M.D.
Assuming this is from the old injury...

I'd go with S93.409S "Sprain of unspecified ligament of unspecified ankle" because the provider didn't specify which ligament or which ankle. Although the previous poster indicated the most frequent ligament involved, without that specified in the documentation I'd be hesitant to assume that's the case here. (If it was the right, it'd be S93.401S; If it was the left ankle, it'd be S93.402S)

I found a reference to a similar situation stating:
"For example: A patient suffers a low back injury that heals on its own. The patient isn’t seeking intervention for the initial injury, but for the pain that persists long after. The chronic pain is sequela of the injury. Such a visit may be reported as G89.21 Chronic pain due to trauma and S39.002S Unspecified injury of muscle, fascia and tendon of lower back, sequela."

Regarding the swelling and pain, you have a couple of options.
G89.11 Acute pain due to trauma - this has an Excludes2 note for:
M25.579 Pain in unspecified ankle and joints of unspecified foot (M25.571 for RT or M25.572 for LT)
R60.0 Localized edema

However, as previously mentioned, if the swelling is due to effusion, the code would be M25.473 Effusion, unspecified ankle (M25.741 for RT, M25.742 for LT). Since pain is, more often that not, a component of effusion, you would not code it separately. Since the provider documented "mild symptoms" and "some swelling", I'm inclined to say this is probably not the case.

I'd go with G89.11, M25.579, R60.0, S93.409S (using the unspecified ankle DXs)