Outpatient Facility Coding Alert

Multiple code options mean you need more specifics.

You have many factors to consider when coding for ankle or foot wounds in ICD-10:  the type of wound, whether it is open or complicated, if tendons are involved, and the laterality of the foot.

Code for Open Ankle Wound from 18 Options

ICD-10 gives open wounds of the ankle its own series of codes (the knee and lower leg also get their own series), with specific codes for right and left ankle and the type of wound (laceration, puncture, open bite).

7th character: At the end of the six-character ICD-10 codes below, you will add a seventh character describing whether it is an initial encounter (A), subsequent encounter (D), or sequela (S).

Example: Report an initial encounter for a puncture wound to the left foot with foreign body as S91.342A.

Muscle and tendon wounds have their own code series in ICD-10. When coding for open wounds of the ankle without tendon involvement, your choices are:

• S91.001x — Unspecified open wound, right ankle
• S91.002x —… left ankle
• S91.009x —… unspecified ankle
• S91.011x — Laceration without foreign body, right ankle
• S91.012x —…left ankle
• S91.019x —… unspecified ankle
• S91.021x — Laceration with foreign body, right ankle
• S91.022x — … left ankle
• S91.029x — … unspecified ankle
• S91.031x — Puncture wound without foreign body, right ankle
• S91.032x —… left ankle
• S91.039x —… unspecified ankle
• S91.041x — Puncture wound with foreign body, right ankle
• S91.042x —… left ankle
• S91.049x —… unspecified ankle
• S91.051x — Open bite, right ankle
• S91.052x —… left ankle
• S91.059x —… unspecified ankle.

Watch for Tendon and Muscle Involvement

ICD-10 also gets much more specific with foot wounds. Open wounds of the foot with tendon and muscle involvement are included in the S92- series (Fracture of foot and toe, except ankle).

• S92.0 Fracture of calcaneus
• S92.1 Fracture of talus
• S92.2 Fracture of other and unspecified tarsal bone(s)
• S92.3 Fracture of metatarsal bone(s)
• S92.4 Fracture of great toe
• S92.5 Fracture of lesser toe(s)
• S92.9 Unspecified fracture of foot and toe

Open foot wounds without tendon involvement are reported with:

• S91.301D — Unspecified open wound, right foot, subsequent encounter
• S91.302A — … left foot, initial encounter
• S91.309D — … unspecified foot, subsequent encounter
• S91.311S — Laceration without foreign body, right foot, sequela
• S91.312S — … left foot, sequela
• S91.311A — Laceration with foreign body, right foot, initial encounter
• S91.312A — … left foot, initial encounter
• S91.331D — Puncture wound without foreign body, right foot, subsequent encounter
• S91.332D — … left foot, subsequent encounter
• S91.309A — … unspecified foot, initial encounter
• S91.341S — Puncture wound with foreign body, right foot, sequela
• S91.342S — … left foot, sequela
• S91.349S — … unspecified foot, sequela
• S91.351S — Open bite, right foot, sequela
• S91.352S — … left foot, sequela
• S91.359S — … unspecified foot, sequela.

---