2025 ICD-10-CM code S94.32XS

Sequela of injury to a cutaneous sensory nerve at the ankle and foot level in the left leg.

Adhere to the official ICD-10-CM coding guidelines, including those for the appropriate use of seventh characters (A, D, and S) to indicate initial encounter, subsequent encounter, or sequela, respectively.Use additional codes to identify the cause of the injury (Chapter 20) and any retained foreign body (Z18.-).

Modifiers may be applicable depending on the circumstances of the visit and treatment provided. Consult the official modifier guidelines for detailed information.

Medical necessity would be established by documentation clearly linking the current symptoms (such as reduced sensation, pain, or functional deficits) to a previously healed injury. This requires thorough documentation of both the acute injury and the subsequent sequelae.

The clinical responsibility involves evaluating the patient's residual symptoms resulting from the healed nerve injury, assessing the extent of the sequelae (such as altered sensation, pain, or functional limitations), and documenting the findings using appropriate medical terminology in the patient's record.This may involve a neurological examination, and potentially, referral to other specialists for further evaluation or management.

IMPORTANT Consider using additional codes from Chapter 20 (External causes of morbidity) to specify the cause of the initial injury.Also, if a retained foreign body is present, use code(s) from category Z18.-.

In simple words: This code describes long-term problems in the left ankle or foot resulting from a past injury to a nerve that carries feeling to the skin.The initial injury is healed, but there are still ongoing issues like numbness or tingling.

This code classifies the late effect (sequela) of an injury affecting the cutaneous sensory nerves located at the ankle and foot level specifically in the left leg.It signifies that the initial injury has healed, but residual effects remain.This code should be used when the injury is no longer acute, and the patient presents with lasting consequences such as numbness, tingling, or altered sensation.

Example 1: A patient presents with persistent numbness and tingling in their left foot, months after a fall resulted in an ankle injury. The initial injury has healed, but sensory nerve damage persists.S94.32XS is used to code this sequela., A patient who had surgery to repair a severely lacerated left ankle several years ago reports lingering numbness along the lateral aspect of their left foot. Following examination, this is documented as a sequela of the previous injury, coded as S94.32XS., A patient sustained a crush injury to their left ankle in a motor vehicle accident two years prior. Physical therapy and other treatments were successful, but there is remaining reduced sensation along the distribution of the superficial peroneal nerve in their left foot. This condition represents a sequela of injury to a cutaneous sensory nerve at the ankle and foot level in the left leg and is coded with S94.32XS.

Thorough documentation is crucial, including a detailed history of the initial injury, the date of the initial injury, descriptions of the current symptoms and their duration, a physical examination of the affected area, findings from any relevant diagnostic testing (such as nerve conduction studies), and the treatment plan.

** This code is specifically for sequelae.Ensure that the initial injury has resolved before using this code.Always utilize the appropriate seventh character to indicate whether the encounter is an initial encounter, a subsequent encounter, or a sequela.

  • Payment Status: Active
  • Modifier TC rule: Not applicable; S94.32XS is a diagnosis code.
  • Specialties:Orthopedics, Neurology, Podiatry
  • Place of Service:Office, Outpatient Hospital, Inpatient Hospital, Other Place of Service
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