Orthopedic Coding Alert

Question: During a level-two evaluation and management (E/M) service for a new patient, the provider diagnoses a “R digital nerve injury.” What is the correct ICD-10 code for this injury?

Washington Subscriber

Answer: Your ICD-10 code choice is rather unclear with this information, so you should try to get some more specifics on the patient’s condition before choosing an ICD-10 code for your 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making …) claim.

The most specific options you have are:

• S64.31X- (Injury of digital nerve of right thumb)
• S64.490- (Injury of digital nerve of right index finger)
• S64.492- (Injury of digital nerve of right middle finger)
• S64.494- (Injury of digital nerve of right ring finger)
• S64.496- (Injury of digital nerve of right little finger).

If all else fails: You can report S64.498- (Injury of digital nerve of other finger) as the diagnosis if you cannot locate any more information on the specifics of the injury.

No matter which ICD-10 code you settle on for your claim, be sure to add the seventh character A (initial encounter), to denote that this was the initial encounter for this patient’s digital injury.