2025 ICD-10-CM code S99
(Active) Effective Date: N/A Injury, poisoning and certain other consequences of external causes - Injury to the ankle and foot 19 Feed
Other and unspecified injuries of ankle and foot.
Medical necessity must be established by documenting the clinical signs, symptoms, and functional limitations caused by the injury. The rationale for the chosen treatment plan must also be recorded.
Clinicians diagnose these injuries through physical examination, focusing on the injured structure and the type of injury.X-rays and MRI scans may be used for more severe injuries. Treatment can involve ice, rest, medication (muscle relaxants, analgesics, NSAIDs), splints or casts, exercises, and surgery in severe cases.
In simple words: This code is used when a person has an injury to their ankle or foot that isn't covered by a more specific code. It can include things like sprains, strains, tears, and cuts, as well as other injuries that doctors can clearly identify but don't have a specific code for.
This code encompasses injuries to the ankle and foot that are not classified elsewhere in the ICD-10-CM. This includes sprains, strains, tears, lacerations, and other unspecified injuries affecting the structures of the ankle and foot.
Example 1: A patient presents with ankle pain and swelling after twisting their foot during a basketball game.The physician diagnoses a sprain, but it doesn't fit the criteria for a specific sprain code. S99 is used., A patient experiences a deep cut on their foot from stepping on broken glass.The laceration is documented, but because there isn't a more specific code for the location and nature of the laceration on the foot, S99 is applied., A child playing soccer gets kicked in the foot, but initial X-rays don’t reveal a fracture. After treatment for soft tissue injury doesn’t relieve symptoms, an MRI shows a tendon tear. Since S99 doesn’t specify a traumatic cause, an external cause code is required.
Detailed documentation of the injury is crucial, including the location, nature (sprain, strain, tear, etc.), and the circumstances surrounding the injury.If known, the cause of the injury should also be documented, which may require an external cause code. Imaging results and treatment plans should also be included.
** 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).
- Specialties:Orthopedics, podiatry, sports medicine, emergency medicine, family medicine
- Place of Service:Office, Home, Inpatient Hospital, On Campus-Outpatient Hospital, Emergency Room - Hospital,Urgent Care Facility,Outpatient Hospital,Ambulatory Surgical Center