2025 ICD-10-CM code S93.516
(Active) Effective Date: N/A Injury, poisoning and certain other consequences of external causes - Injury to the ankle and foot 19 Feed
Sprain of interphalangeal joint of unspecified lesser toe(s).
Use A, D, or S for initial encounter, subsequent encounter, or sequela, respectively.
Medical necessity is established by the physician's documentation of the injury, supporting the need for treatment.The documentation should reflect the severity of the sprain and the impact on the patient's function.
Providers diagnose the condition based on the patient’s history; physical examination; assessment of range of motion and feeling in the affected region; and imaging techniques such as X–rays, computed tomography, magnetic resonance imaging, and ultrasound. Treatment options depend upon the severity of the sprain and include rest, application of ice pack, elevation of the affected extremity, immobilization with a cast, brace, and/or the use of crutches; physical therapy; and medication such as analgesics, muscle relaxants, and nonsteroidal antiinflammatory drugs to relieve pain. Severe sprains may require surgery to repair torn ligaments.
In simple words: A sprain in one of the small joints of your toe, but the doctor didn't specify which toe or which foot.
Sprain of the interphalangeal joint of an unspecified lesser toe refers to stretching or tearing of the ligaments, the fibrous bands of tissue that connect and support the joint between two phalanges or bones of the toe.
Example 1: A patient presents to the ER after twisting their toe playing soccer.Exam reveals a sprain of the interphalangeal joint of the fourth toe, but the physician's documentation does not specify right or left. Code S93.516 is used., A patient presents to their PCP with ongoing foot pain from a previous toe injury. Imaging shows a healed sprain of an interphalangeal joint of a lesser toe. Since the specific toe and laterality are not documented, S93.516 is reported., A patient is seen for a follow-up visit for a sprained toe. The initial documentation clarified it was a right lesser toe. However, during this visit, the doctor simply notes "improving sprain, lesser toe," omitting the laterality.Code S93.516 would be appropriate.
Laterality (if known), specific toe (if known) and Initial/Subsequent/Sequela should be documented by provider.If any of these are unspecified, use the appropriate unspecified ICD-10 code. Documentation should also include details of the cause of the injury, symptoms, and treatment plan.
** Use additional code to identify any retained foreign body, if applicable (Z18.-).
- Specialties:Orthopedics, Emergency Medicine, Primary Care, Sports Medicine
- Place of Service:Office, Home,Inpatient Hospital, On Campus-Outpatient Hospital, Emergency Room - Hospital,Outpatient Hospital,Urgent Care Facility