ICD-10 CODES FOR The 12-year-old male patient was brought to the emergency department with severe pain and swelling of his left ankle. He sustained the injury when he fell off his skateboard on the school playground. An X-ray showed a simple trimalleolar fracture of his left ankle. The fracture was reduced and he was placed in a long leg cast
The Correct Answer and Explanation is:
ICD-10 Codes:
- S82.852A – Other trimalleolar fracture of left lower leg, initial encounter for closed fracture
- W02.0XXA – Fall involving (nonmotorized) scooter, skateboard, or rollerskates, initial encounter
- Y92.210 – School playground as the place of occurrence of the external cause
- Y93.55 – Activity involving skateboarding
Explanation
The process of selecting accurate ICD-10-CM codes begins with identifying the main diagnosis and the circumstances surrounding the injury. In this case, a 12-year-old male sustained a trimalleolar fracture of the left ankle due to a fall from a skateboard. A trimalleolar fracture involves all three malleoli of the ankle: the lateral, medial, and posterior malleolus. The description states that the fracture is simple and was successfully reduced, with the patient placed in a long leg cast, indicating a closed injury.
The primary code selected is S82.852A, which describes “Other trimalleolar fracture of the left lower leg,” with the 7th character “A” indicating initial encounter for closed fracture. The term “other” is used because this fracture does not fall into a more specific subclass under trimalleolar fractures.
The external cause of the injury is essential to fully describe the encounter. The patient fell off a skateboard, so the appropriate external cause code is W02.0XXA — this represents a fall involving a nonmotorized wheeled device like a skateboard. The “XX” placeholders are necessary to ensure the 7th character “A” (for initial encounter) is correctly placed.
Additionally, place of occurrence should be coded when known. Since the accident occurred on a school playground, Y92.210 is used.
To complete the clinical picture, Y93.55 is added to indicate the activity the patient was engaged in — skateboarding — at the time of the injury.
These codes help providers, insurers, and public health officials understand not just the injury but its context, which is vital for treatment, billing, and injury prevention analysis.
