ICD-10 Coding for Right Ankle Pain(M25.571, S93.411A, M19.071)
Complete ICD-10-CM coding and documentation guide for Right Ankle Pain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Ankle Pain
M25.57-M25.579Primary Range
Pain in joint
This range includes codes for pain in joints, specifically focusing on the right ankle.
Sprain and strain of ankle
This range includes codes for sprains and strains of the ankle, relevant for traumatic injuries.
Primary osteoarthritis of ankle
This range includes codes for osteoarthritis affecting the ankle, which can cause chronic pain.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M25.571 | Pain in right ankle and foot | Use when the pain is idiopathic or nonspecific without clear traumatic cause. |
|
| S93.411A | Sprain of calcaneofibular ligament of right ankle, initial encounter | Use for acute traumatic injuries involving the calcaneofibular ligament. |
|
| M19.071 | Primary osteoarthritis, right ankle | Use for chronic degenerative changes in the right ankle. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for right ankle pain
Essential facts and insights about Right Ankle Pain
Primary ICD-10-CM Codes for right ankle pain
Decision Criteria
clinical Criteria
- Pain is localized to the right ankle without trauma.
documentation Criteria
- Documentation includes laterality and excludes trauma.
Applicable To
- Generalized pain in right ankle
Excludes
- Pain due to injury (S93.4-)
Clinical Validation Requirements
- Patient reports pain localized to right ankle
- Physical exam shows tenderness in the right ankle
Code-Specific Risks
- Risk of using unspecified codes if laterality is not documented.
Coding Notes
- Ensure documentation specifies laterality and excludes traumatic causes.
S93.411A - Sprain of calcaneofibular ligament of right ankle, initial encounter
Use for acute traumatic injuries involving the calcaneofibular ligament.
Applicable To
- Acute sprain of right ankle ligament
Excludes
- Chronic ligament injury (M24.27-)
Clinical Validation Requirements
- MRI or ultrasound confirming ligament tear
- Positive anterior drawer test
Coding Notes
Document the mechanism of injury and specific ligament involved.
M19.071 - Primary osteoarthritis, right ankle
Use for chronic degenerative changes in the right ankle.
Applicable To
- Degenerative joint disease of right ankle
Excludes
- Post-traumatic osteoarthritis (M19.27-)
Clinical Validation Requirements
- X-ray showing joint space narrowing
- Clinical history of chronic pain
Coding Notes
Ensure chronicity and degenerative nature are documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Chronic pain, not elsewhere classified
G89.29Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Osteophyte, right ankle
M25.371Sprain of unspecified ligament of right ankle, initial encounter
S93.401APost-traumatic osteoarthritis, right ankle
M19.271Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Right Ankle Pain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M25.571.
Impact
Clinical: Leads to inaccurate diagnosis and treatment., Regulatory: Increases risk of audit and compliance issues., Financial: May result in claim denials or reduced reimbursement.
Mitigation Strategy
Always include laterality in clinical notes., Use templates that prompt for laterality.
Impact
Reimbursement: May lead to claim denials due to lack of specificity., Compliance: Increases risk of audit due to unspecified coding., Data Quality: Reduces accuracy of clinical data.
Mitigation Strategy
Document the specific ligament involved in the injury.
Impact
High risk of audit when unspecified codes are used without justification.
Mitigation Strategy
Ensure documentation supports the use of specific codes.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Right Ankle Pain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Ankle Pain
Use these documentation templates to ensure complete and accurate documentation for Right Ankle Pain. These templates include all required elements for proper coding and billing.
Orthopedic evaluation for right ankle pain
Specialty: OrthopedicsRequired Elements
- Patient history
- Physical examination findings
- Imaging results
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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