Unspecified sprain of left great toe, initial encounter

This diagnosis code signifies a sprain of the left great toe where the specific ligament or joint involved is not documented. It indicates an acute injury to the soft tissues supporting the metatarsophalangeal joint of the hallux. The "initial encounter" designation means the patient is receiving active treatment for this injury.

This code is appropriate for the first visit or active phase of treatment for a patient presenting with pain, swelling, and tenderness in the left great toe following a traumatic event, such as stubbing the toe or a sports injury, when the physician has not specified the exact ligament sprained. It is used when the documentation confirms a sprain but lacks further anatomical detail.

• Ensure documentation clearly states "left great toe" and "sprain" without further specificity.
• Verify the "initial encounter" status; subsequent encounters for the same injury will require a different seventh character.
• If the specific ligament (e.g., collateral ligament) is identified, a more precise code should be used.