ICD-10-CM Billable Code

S94.11

Injury of medial plantar nerve, right leg

Clinical Classification Guidelines

Medical Intelligence & Overview

An injury to the medial plantar nerve in the right leg, classified under ICD-10 code S94.11, involves damage to a key nerve that supplies sensation and motor function to parts of the foot. This nerve is a branch of the tibial nerve and plays a critical role in foot movement and feeling. Such injuries can result from trauma, compression, or other medical conditions, impacting daily activities and quality of life. Recognizing the causes and symptoms can facilitate timely medical diagnosis and management.

Causes & Symptoms

Clinical Causes: Trauma or direct injury to the foot or leg, such as fractures, lacerations, or blunt force impacts Surgical procedures involving the foot, ankle, or lower leg that may inadvertently damage the nerve Chronic pressure or compression from ill-fitting footwear, orthotic devices, or anatomical abnormalities Entrapment syndromes caused by swelling, inflammation, or tumors compressing the nerve Diabetic neuropathy leading to nerve degeneration Repetitive stress injuries from activities that involve repeated foot movements

Key Symptoms: Sensation loss or numbness on the bottom of the foot, particularly the medial (inner) side Pain localized along the nerve path, which may worsen with activity or pressure Tingling or burning sensations in the sole of the foot Weakness in specific muscles responsible for toe movements, leading to difficulty in walking or standing Decreased ability to sense textures or temperatures on the affected area Possible development of foot deformities or abnormal gait over time if untreated

Diagnostic & Treatment

Diagnosis Path: Diagnosis typically involves a comprehensive medical history review and physical examination focused on foot sensation and motor function. Healthcare providers may perform nerve conduction studies and electromyography (EMG) to assess nerve activity and muscle response. Imaging techniques like MRI or ultrasound can help identify structural causes, such as entrapment or injury to surrounding tissues. Accurate diagnosis is essential for tailored treatment planning.

Treatment Protocols: Management approaches depend on the severity and cause of the nerve injury. Common strategies include: - Rest and activity modification to prevent further nerve damage - Physical therapy aimed at strengthening surrounding muscles and improving mobility - Medications to control pain or reduce inflammation - Use of orthotic devices or braces to offload pressure from the nerve - Surgical intervention may be necessary in cases of persistent compression or structural injury - Regular monitoring and follow-up to assess nerve recovery and adapt treatment as needed

Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Clinical Advice & FAQs

Billing Guidance

Is S94.11 a billable ICD-10 code?
Yes, S94.11 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report S94.11?
Clinical documentation must specify the nature of Injury of medial plantar nerve, right leg and any associated comorbidities for accurate reporting.

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