Neurology & Pain Management Coding Alert

Question: A patient received pain treatment for a right Achilles injury; there is no other information on the injury the patient suffered. Notes indicate that it was a subsequent encounter to treat the injury. Which ICD-10 code should I report for this patient?

Montana Subscriber

Answer: For your encounter, you should report S86.001D (Unspecified injury of right Achilles tendon, subsequent encounter) to represent the patient’s injury. There are more specific Achilles injury diagnosis codes, but it doesn’t look like you have enough information to make assign a more specific ICD-10 code to this patient.

Other options: Some other codes you might choose from for your patients’ Achilles injuries are:

• S86.011X (Strain of right Achilles tendon)
• S86.021X (Laceration of right Achilles tendon)
• S86.091X (Other specified injury of right Achilles tendon)

Seventh character alert: For your encounter, you’ll need seventh character D (subsequent encounter) to indicate that it was a subsequent encounter for this injury. If it was the initial encounter for the Achilles injury, you’d choose A (initial encounter) as a seventh digit; if the visit was sequala, choose S (sequala) as the seventh character.