Ankle Fracture ICD-10-CM codes

Ankle fractures are coded within the lower leg category S82. S82.5- is fracture of the medial malleolus (tibia) and S82.6- fracture of the lateral malleolus (fibula); in both, the fifth character reports displacement and laterality (S82.61 displaced lateral malleolus right, S82.62 left, S82.63 unspecified side, S82.64 to S82.66 nondisplaced). Because these codes have only five characters, X fills the sixth position: S82.61XA. Bimalleolar fractures are S82.84- and trimalleolar fractures S82.85-, with a sixth character for displacement and laterality (S82.841A displaced bimalleolar right, S82.851A displaced trimalleolar right). Maisonneuve fractures are S82.86- and pilon fractures S82.87-.

S82 uses the expanded seventh characters with the Gustilo classification: A closed initial, B open type I or II, C open type IIIA to IIIC, D to R subsequent encounters by healing and open or closed status, S sequela. Apply the defaults from the guidelines when documentation is silent: closed, displaced, and type I or II for an open fracture without a Gustilo grade. Surgical fixation on the initial admission is still an A encounter.

Fractures of the talus and calcaneus are ankle and foot fractures in S92 (S92.001A unspecified calcaneus, right), not S82. An ankle sprain without fracture is S93.4- (S93.401A). Report both when a fracture and a ligament injury are documented. Add the external cause code (for example W01.0XXA) and place of occurrence on the initial encounter.