Ankle and Knee Sprains ICD-10-CM codes

An ankle sprain is S93.4- with the fifth character naming the ligament: S93.40- unspecified ligament, which is the default for an ankle sprain not further described, S93.41- calcaneofibular, S93.42- deltoid, S93.43- tibiofibular (the high ankle or syndesmotic sprain), and S93.49- other. The sixth character is laterality (S93.401A right, S93.402A left, S93.409A unspecified), and the seventh is A initial, D subsequent, or S sequela.

Knee ligament injuries are in S83. S83.4- is sprain of the collateral ligaments (S83.41- medial collateral, S83.42- lateral collateral), S83.5- sprain of the cruciate ligaments (S83.51- anterior cruciate, S83.52- posterior cruciate), and S83.6- sprain of the superior tibiofibular joint. In ICD-10-CM a traumatic tear of a knee ligament is coded to the same sprain code; the index sends an anterior cruciate ligament tear to S83.51- (S83.511A right). Meniscal tears are separate, in S83.2- (S83.241A medial meniscus, right). Grade of sprain does not change the code.

Sprains involve ligaments and joints; strains involve muscles and tendons and are coded to the muscle injury categories (S76 for the thigh, S86 for the lower leg, S96 for the foot), so read the documentation for which structure was injured. A sprain of the foot rather than the ankle is S93.6- (S93.601A). Add an external cause code such as X50.0XXA (overexertion) or an activity code (Y93.61 American tackle football, Y93.64 baseball) on the initial encounter when documented.