2025 ICD-10-CM code S94.32XD

Injury of cutaneous sensory nerve at ankle and foot level, left leg, subsequent encounter.

Adhere to official ICD-10-CM coding guidelines. Use additional codes as needed to specify associated conditions or external causes.

Medical necessity is established by the presence of an ongoing injury to the cutaneous sensory nerves of the left ankle and foot necessitating further evaluation and management to assess healing, address symptoms, and prevent complications.

The clinical responsibility involves evaluating the patient's ongoing symptoms and the healing process of the injured nerve.This might include assessing sensory function, managing pain, monitoring for complications, and providing appropriate treatment and follow-up care.

IMPORTANT Consider using additional codes to specify any associated open wounds (S91.-) or retained foreign bodies (Z18.-).Also, if the injury is caused by a specific external factor, a secondary code from Chapter 20 (External causes of morbidity) should be used.

In simple words: This code describes a follow-up visit for an injury to the nerves that feel sensation in the left ankle and foot.The initial injury has already been treated, and this code is used to track any further care or check-ups.

This ICD-10-CM code classifies a subsequent encounter for an injury affecting the cutaneous sensory nerves located at the ankle and foot level of the left leg.This implies that the initial injury has been previously treated, and this code reflects ongoing care or follow-up related to that injury.The code specifically targets damage to the nerves responsible for transmitting sensory information from the skin in the affected area.

Example 1: A patient presents for a follow-up visit three weeks after an initial injury to the left ankle and foot, sustained during a fall.The patient is experiencing ongoing numbness and tingling in the affected area., A patient, who had a previous surgical repair of a nerve injury in their left ankle sustained in a motor vehicle accident, returns for a post-operative check-up., A patient with a chronic condition causing nerve damage in the left foot experiences a worsening of symptoms and seeks medical attention for pain management and assessment of nerve function.

Complete documentation should include a detailed history of the initial injury, date of injury, mechanism of injury, prior treatment (if any), current symptoms (pain, numbness, tingling, weakness), physical examination findings, and any relevant imaging studies (such as nerve conduction studies).

** Excludes1: Birth trauma (P10-P15), obstetric trauma (O70-O71); Excludes2: Burns and corrosions (T20-T32), fracture of ankle and malleolus (S82.-), frostbite (T33-T34), insect bite or sting, venomous (T63.4).

  • Payment Status: Active
  • Specialties:Neurology, Orthopedics, Podiatry
  • Place of Service:Office, Outpatient Hospital, Clinic
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