2025 ICD-10-CM code S85

Injury of blood vessels at the lower leg level.

Always code the injury to the blood vessel.If an open wound is present, code that separately (S81.-).Use additional codes to indicate the specific vessel injured if known, and use appropriate 7th character codes to specify the encounter.Refer to the official ICD-10-CM guidelines for further clarification.

Modifiers may be used to indicate laterality (right or left leg) and other relevant circumstances as per official coding guidelines.

Medical necessity for treatment of lower leg blood vessel injury is established by the presence of symptoms such as significant bleeding, pain, swelling, or impairment of lower leg function.The severity of the injury and the potential for complications (e.g., limb ischemia, compartment syndrome) must be considered when determining the appropriateness of interventions such as surgical repair, anticoagulation, or other treatments.

The clinical responsibility includes diagnosing the injury through history taking, physical examination (including vascular assessment), ordering and interpreting laboratory tests (coagulation studies, platelet count, BUN, creatinine if contrast imaging is planned), ordering and interpreting imaging studies (X-rays, ultrasound, venography, arteriography), managing bleeding (pressure, potential surgical intervention), prescribing medications (anticoagulants, antiplatelets, analgesics), and performing any necessary surgical procedures.

IMPORTANT Code also any associated open wound (S81.-).Excludes injury of blood vessels at ankle and foot level (S95.-).Additional codes may be necessary to specify the laterality (right or left) and the specific blood vessel involved, as well as the encounter status (initial or subsequent).

In simple words: Damage to blood vessels in the lower leg, often from an accident or injury.This can cause bleeding, pain, and swelling. Doctors diagnose it with exams and imaging, and treatment might include pressure on the wound, medication, or surgery.

Injury of blood vessels at the lower leg level refers to damage to the blood vessels supplying the lower leg.This can be caused by blunt or penetrating trauma (e.g., motor vehicle accident, sports injury, gunshot wound), external compression or force, abnormal bending or twisting of the leg, iatrogenic injury during surgery, or other trauma.The injury may result in hemorrhage, thrombus formation, thrombophlebitis, hypotension, and cool, pale skin. Diagnosis involves patient history, physical examination (including nerve and vascular assessment), laboratory studies (coagulation factors, platelets, BUN, creatinine), and imaging (X-rays, ultrasound, venography, arteriography). Treatment may include pressure to control bleeding, anticoagulation or antiplatelet therapy, analgesics, and potentially surgical repair.

Example 1: A patient presents to the emergency department after a motor vehicle accident with a laceration to the lower leg and significant bleeding.The physician diagnoses an injury to the posterior tibial artery. The patient undergoes surgical repair of the artery and receives a blood transfusion. , A soccer player sustains a direct blow to the calf during a game resulting in ecchymosis and localized pain.Ultrasound reveals a small hematoma and a minor injury to the soleal vein. Conservative management with ice, elevation, and analgesics is initiated., A patient undergoes a lower leg amputation due to severe peripheral vascular disease. During surgery, an iatrogenic injury to a smaller leg vein occurs, resulting in minor bleeding which is successfully controlled during the procedure.

Detailed patient history including mechanism of injury, physical examination findings (including location, size, and character of any wounds), results of laboratory studies (coagulation profile, complete blood count), imaging studies (ultrasound, angiography if indicated), operative report if surgery is performed, and details of any post-operative management.

** This code is non-billable unless further specified by additional codes to describe the specific blood vessel involved and the laterality.Consider using additional codes from Chapter 20 (External Causes of Morbidity) to specify the cause of injury.

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