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Physical Therapy

Physical Therapy

  • Andrea Ryan

A Comprehensive Guide to ICD-10 Codes for Lower Leg Injury

It is very common for feet and ankles to be injured in sports and even in everyday situations. Podiatrists and physical therapists see millions of Americans annually for foot and ankle problems as sports-related injuries. The United States sees more than 3 million emergency room visits due to foot and ankle injuries every year (2017 statistics). The foot and ankle are considered complex body structures that balance and support the body's weight while providing complete mobility. Physically active individuals are more likely to suffer injuries when they engage in repetitive motions or sports activities that require running, jumping or quick direction changes, such as basketball, soccer, hockey, football and cricket. Various types of foot injuries require a comprehensive treatment plan developed by physical therapists. These complex foot procedures can be challenging to code and bill, as there are several rules to follow.


An ankle or foot sprain is typically caused by partially torn or completely ruptured ligaments. In the affected areas, severe pain, swelling, stiffness, tenderness or bruising are common symptoms. Standing or walking for an extended period of time can also cause serious difficulty for some people. Symptoms of foot or ankle pain can range from minor to chronic, which may indicate a more serious condition that needs treatment, but many of the most common symptoms can be treated with physical therapy. The treatment and prevention of different types of foot and ankle injuries requires a combination of warm-ups and conditioning, the use of braces, splints, and casts, as well as other pain management methods.





Here are some common injuries that occur to the feet and ankles, as well as their causes, treatment options, and diagnosis codes:


Achilles Tendinitis


This condition is caused by repeated or intense strain on the Achilles tendon, which connects your calf muscles to your heel bone. This is an overuse injury that is common among runners who increase their intensity or duration suddenly. Tennis or basketball players in their middle ages may also develop this condition.


In most cases, leg pain begins as a mild ache above or behind the heel. In mild cases, self-care measures can be used to treat this condition. It may help to relieve pain and strain on the tendon by taking over-the-counter medications (such as ibuprofen, Advil, Motrin IB, others) or naproxen, performing physical therapy exercises, and wearing orthotic devices. In severe cases, however, physical therapy or even surgery may be required to repair a ruptured tendon.


Achilles tendinitis ICD-10 codes include:


  • M76.6 Achilles tendinitis

  • M76.60 Achilles tendinitis, unspecified leg

  • M76.61 Achilles tendinitis, right leg

  • M76.62 Achilles tendinitis, left leg


Shin splints


Inflammation of the muscles, tendons, and bone tissue around your tibia can cause shin splints (a pain in the front of your lower leg). The condition is also known as Medial/Anterior Tibial Stress Syndrome and often occurs when an athlete increases their training routines or changes them. It is common to feel tender, sore or painful along the inner side of your shinbone as well as mild swelling in your lower leg.


The first step in diagnosing this condition is to evaluate the patient's medical history and conduct a physical examination. A stress fracture, for example, can be detected with X-rays or other imaging studies. This injury condition can be treated with rest, ice, medications, and other self-care measures. In order to prevent pain, swelling, and discomfort, patients should stay away from activities that cause them discomfort. The affected shin can be protected and prevented from swelling by applying ice packs for 15 to 20 minutes at a time (4 to 8 times a day) for several days. Pain may be relieved by taking over-the-counter pain relievers such as ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve), or acetaminophen (Tylenol). Additionally, you can prevent recurrence of shin splints by wearing the right type of footwear and changing your exercise routine. In severe cases of shin splints or stress fractures, physical therapy may be recommended for recovery.


The following ICD-10 codes can be used for reimbursement purposes:


  • M76.81 Anterior tibial syndrome

  • M76.811 Anterior tibial syndrome, right leg

  • M76.812 Anterior tibial syndrome, left leg

  • M76.819 Anterior tibial syndrome, unspecified leg


Ankle sprain


Whenever you roll, twist, or turn your ankle in an awkward way, you risk this injury. Ligaments hold your ankle bones together and can be stretched or torn leading to an ankle sprain. Sprained ankles are typically caused by injuries to the outer ankle ligaments. An ankle twist injury can result from several causes such as a fall, landing awkwardly on your foot after jumping or pivoting, walking or exercising on an uneven surface, and being stepped on by someone during a sport.


Ankle sprains are generally characterized by pain, swelling, tenderness, bruising, inability to bear weight on the affected ankle, and skin discoloration. In addition to home-care measures (such as braces, ACE bandages, crutches, applying ice packs, and keeping your ankle elevated), medication (such as ibuprofen (such as Advil) or acetaminophen (such as Tylenol)) is also used to treat pain. Physical therapy exercises will be recommended to regain your ankle's flexibility, strength, and range of motion once the swelling has subsided.


ICD-10 codes for the comprehensive treatment of ankle sprain include:


  • S93.4 Sprain of ankle

  • S93.40 Sprain of unspecified ligament of ankle

  • S93.401 Sprain of unspecified ligament of right ankle

  • S93.401A Sprain of unspecified ligament of right ankle, initial encounter

  • S93.401D Sprain of unspecified ligament of right ankle, subsequent encounter

  • S93.401S Sprain of unspecified ligament of right ankle, sequela

  • S93.402 Sprain of unspecified ligament of left ankle

  • S93.402A Sprain of unspecified ligament of left ankle, initial encounter

  • S93.402D Sprain of unspecified ligament of left ankle, subsequent encounter

  • S93.402S Sprain of unspecified ligament of left ankle, sequela

  • S93.409 Sprain of unspecified ligament of unspecified ankle

  • S93.409A Sprain of unspecified ligament of unspecified ankle, initial encounter

  • S93.409D Sprain of unspecified ligament of unspecified ankle, subsequent encounter

  • S93.409S Sprain of unspecified ligament of unspecified ankle, sequela


Plantar fasciitis


Inflammation of this thick band of tissue connects the heel bone to the toes that runs across the bottom of your foot (plantar fascia) is one of the most common causes of heel pain (plantar fasciitis). You usually feel stabbing heel pain when you take your first steps in the morning due to this condition. The condition is more common among runners. Additionally, those who wear shoes without adequate support and those who are overweight are at an increased risk.


Conservative treatments for plantar fasciitis include medication, icing, stretching, and resting. Pain and inflammation can be relieved by doing physical therapy exercises. It may be possible to distribute pressure more evenly to your feet with the use of night splints and custom-made arch supports (orthotics). In the long run, the condition may be prevented by avoiding activities that place additional strain on the foot and by wearing proper fitting shoes.


ICD-10 codes related to treatment of plantar fasciitis include:


  • M72 – Fibroblastic disorders

  • M72.0 – Palmar fascial fibromatosis [Dupuytren]

  • M72.1 – Knuckle pads

  • M72.2 – Plantar fascial fibromatosis

  • M72.4 – Pseudosarcomatous fibromatosis

  • M72.6 – Necrotizing fasciitis

  • M72.8 – Other fibroblastic disorders

  • M72.9 – Fibroblastic disorder, unspecified


Hammertoe


Hammertoe occurs when the middle joint of a toe bends abnormally. When you have this condition, your toes bend or curl downward rather than pointing forward. In most cases, the second or third toe is affected by this foot deformity. There are many factors that contribute to this foot condition, including the type of shoes you wear, your foot structure, traumatic toe injuries, arthritis, and an unusually high foot arch. It is characterized by a toe that bends downward, difficulty flexing your foot or wiggling your toes, corns or calluses, and claw-like toes.


The most effective way to treat hammertoe is to wear shoes that fit properly. Toe pads or insoles can help if a high arch is causing the problem. These pads correct your toe's appearance by shifting its position, which alleviates your pain and corrects its appearance. In the event that the toe condition is becoming painful or causing the toes to become deformed, podiatrists would perform surgery to reposition the toe and restore motion, and following this surgery, physical therapy would be prescribed for recovery.


Toe deformity ICD-10 codes include:


  • M20.4 Other hammer toe(s) (acquired)

  • M20.40 Other hammer toe(s) (acquired), unspecified foot

  • M20.41 Other hammer toe(s) (acquired), right foot

  • M20.42 Other hammer toe(s) (acquired), left foot


Stress fractures


A stress fracture is caused by repeated force, such as excessive jumping or running long distances, causing tiny cracks in the bone. A weak bone, such as one affected by osteoporosis, can also cause the condition. Weight-bearing bones in the legs and feet are more likely to be fractured in this way. The initial days after a fracture may be painless for patients. There will be tenderness and swelling in a specific spot as the condition progresses, which will decrease with adequate rest. In some cases, it may be helpful to wear a walking boot, use crutches, or wear a brace to reduce the symptoms.


The following ICD-10 codes are used for stress fractures:


  • M84.37 Stress fracture, ankle, foot and toes

  • M84.371 Stress fracture, right ankle

  • M84.372 Stress fracture, left ankle

  • M84.373 Stress fracture, unspecified ankle

  • M84.374 Stress fracture, right foot

  • M84.375 Stress fracture, left foot

  • M84.376 Stress fracture, unspecified foot

  • M84.377 Stress fracture, right toe(s)

  • M84.378 Stress fracture, left toe(s)

  • M84.379 Stress fracture, unspecified toe(s)

  • M84.38 Stress fracture, other site


In order to report common foot and ankle injuries, physical therapists must be familiar with the ICD-10 codes. Providers in this specialty can maximize reimbursement by utilizing qualified billing services provided by experienced service providers like PatientStudio. Schedule a demo with a PatientStudio representative today to see how easy ICD-10 code search can be within their physical therapy patient management software.


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