ICD Code S93.491A

ICD code S93.491A is a sprain of another ligament in the right ankle, during the patient's initial encounter for this injury.

1. Patient presents with acute right ankle pain following trauma or injury.

2. Physical examination reveals swelling, tenderness, and possible bruising localized to the right ankle.

3. Instability or difficulty bearing weight on the right ankle is noted.

4. Ligamentous injury is suspected based on mechanism of injury (e.g., twisting, rolling, or impact).

5. No evidence of fracture on imaging studies (if performed).

6. Diagnosis confirms sprain involving a ligament of the right ankle other than the commonly specified ones (e.g., not anterior talofibular, calcaneofibular, or deltoid ligaments).

7. This is the patient’s initial encounter for evaluation and treatment of this injury.

Relevant CPT codes that may be used to treat ICD code S93.491A include:

- 99201–99205 (Office or other outpatient visit, new patient)

- 99211–99215 (Office or other outpatient visit, established patient)

- 29515 (Application of short leg splint)

- 29540 (Strapping; ankle and/or foot)

- 73600 (Radiologic examination, ankle; 2 views)

- 73610 (Radiologic examination, ankle; complete, minimum of 3 views)

- 97110 (Therapeutic exercises)

- 97140 (Manual therapy techniques)

- 97750 (Physical performance test or measurement)

- 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)), if indicated

CPT code selection should be based on the specific services provided for ICD code S93.491A.

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