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2025 ICD-10-CM code S90

Superficial injury of ankle, foot and toes.

Refer to the official ICD-10-CM coding guidelines for further information on coding superficial injuries and the use of additional codes.

Medical necessity is established by the presence of a superficial injury requiring treatment to prevent infection, control pain, and facilitate healing.Documentation should support the clinical need for the services provided.

Diagnosis is based on patient history and physical exam.Treatment may involve wound care, pain management, infection prevention, and tetanus prophylaxis as needed.Foreign bodies may require X-ray localization and removal.

IMPORTANT:Use additional code Z18.- to identify any retained foreign body, if applicable.Use secondary code(s) from Chapter 20 (External causes of morbidity) to indicate the cause of injury. Codes in the T section that include the external cause do not require an additional external cause code.

In simple words: This code describes a minor injury to the ankle, foot, or toes, such as a scrape, cut, blister, bruise, or small wound.It might involve a small cut needing a bandage, or a bruise that's not very serious.A doctor will check it to make sure it's not infected and may clean it and give you advice.

A superficial injury of the ankle, foot, and/or toes involves a minimal scrape, cut, blister, bite, bruise, external constriction, foreign body, or other minor wound due to trauma or surgery.It can result in minimal bleeding, minor pain, swelling, inflammation, discoloration, tenderness, itching, and possible infection in the case of an open wound or bite. Diagnosis is based on patient history and physical examination; injuries with foreign bodies may require X-rays. Treatment may include stopping bleeding, foreign body removal, wound cleaning, antiseptic/antibiotic application, suturing (if necessary), wound dressing, analgesics/NSAIDs for pain and inflammation, antibiotics (if needed), and tetanus prophylaxis (if necessary).

Example 1: A patient presents with a small laceration on their ankle after tripping. The wound is cleaned, a bandage is applied, and tetanus prophylaxis is administered., A child steps on a sharp object, resulting in a puncture wound to the foot.The foreign body is removed, the wound is cleaned and dressed.Antibiotics are prescribed to prevent infection., An athlete sustains a superficial abrasion to their toes during a sporting event.The abrasion is cleaned and a dressing is applied.The athlete is advised on wound care and given pain relief medication.

Detailed description of the injury (location, size, depth), mechanism of injury, wound cleaning and treatment, application of dressings, administration of medication, tetanus prophylaxis administration, imaging results (if any), and patient instructions.

** Excludes burns and corrosions (T20-T32), fracture of ankle and malleolus (S82.-), frostbite (T33-T34), and venomous insect bites or stings (T63.4).The seventh character (A, D, or S) should be appended to indicate the encounter (initial, subsequent, or sequela).

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