2025 ICD-10-CM code S95

Injury of blood vessels at the ankle and foot level.

Appropriate selection of additional codes is crucial for accurate billing and reimbursement.Always code the cause of injury using codes from Chapter 20, and code any associated open wounds or retained foreign bodies using the appropriate codes.

Modifiers may be applicable depending on the circumstances of the procedure. For example, modifiers could indicate the location (right or left), or the use of anesthesia, or the type of service (e.g., initial encounter vs. subsequent encounter).

Medical necessity for the treatment of vascular injuries at the ankle and foot level is established by the presence of significant bleeding, compromised blood flow, threat of limb ischemia, or the need for surgical repair to restore normal perfusion.

The clinical responsibility includes diagnosing the injury through patient history, physical examination, lab tests, and imaging studies. Treatment may involve surgical repair, medication management, and post-operative care.

IMPORTANT Use additional code to identify any retained foreign body (Z18.-).A secondary code from Chapter 20 (External causes of morbidity) should be used to indicate the cause of injury.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).Also code any associated open wound (S91.-). Excludes injury of posterior tibial artery and vein (S85.1-, S85.8-)

In simple words: This code describes damage to blood vessels in your ankle or foot, often from an accident, injury, or surgery.It can cause pain, bleeding, swelling, and discoloration. Doctors diagnose it through exams and tests, and treatment might involve surgery or medication.

Injury of blood vessels at the ankle and foot level refers to damage, cutting, or tearing of blood vessels in the ankle and foot.This injury is typically caused by blunt or penetrating trauma from events such as traffic accidents, sports activities, surgery, crush injuries, puncture wounds, or gunshot wounds.The injury may result in pain, severe bleeding, hematoma (blood clot), weakness, hypotension (low blood pressure), skin discoloration, coldness in the affected area, and pseudoaneurysm (a collection of blood outside a damaged artery). Diagnosis involves patient history, physical examination (assessing sensation, reflexes, blood supply, and bruits), blood tests (hemoglobin, hematocrit, coagulation factors, platelets), and vascular imaging (angiography, ultrasound). Treatment options include hemorrhage control, surgical repair (possibly with stents), blood transfusions (if necessary), anticoagulation or antiplatelet therapy, pain medication, and observation.

Example 1: A patient presents to the emergency room after a motor vehicle accident with an open fracture of the tibia and fibula, and significant bleeding from a lacerated artery at the ankle.S95 would be used to code the vascular injury in conjunction with codes for the fractures and open wound., During a surgical procedure to repair a fractured ankle, a surgeon accidentally lacerates a blood vessel.S95 would be used to code the iatrogenic vascular injury, along with codes to describe the surgical procedure itself., A patient sustains a deep puncture wound to the foot from stepping on a sharp object, resulting in damage to a blood vessel and significant bleeding. S95 would be used to code the vascular injury, along with a code for the puncture wound.

Detailed documentation should include the mechanism of injury, location and extent of vascular damage, results of physical examination, lab values, imaging studies (angiography, ultrasound), surgical findings (if applicable), and the type and extent of treatment rendered.

** The seventh character (A, D, or S) should be appended to the code to specify the encounter status (initial encounter, subsequent encounter, or sequela). Always confirm the code's accuracy with the latest ICD-10-CM coding guidelines.Consult with a coding specialist for complex cases.

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