Strain muscles and tendons at ank/ft level, unsp foot, subs

This code signifies a muscle or tendon strain in the ankle or foot region, excluding the Achilles tendon, that is being treated in a follow-up visit. The specific muscle or tendon involved is not identified, and the affected foot is also unspecified.

Apply this code for patients presenting for ongoing care, such as physical therapy, re-evaluation, or medication refills, for a previously diagnosed and treated strain of an unspecified muscle or tendon in the ankle or foot. This is appropriate when the initial injury was not to the Achilles tendon and the laterality was not documented.

• Ensure the "D" seventh character is appropriate for a subsequent encounter; do not use for initial or sequela encounters.
• Avoid this code if a more specific muscle or tendon is documented; search for codes within the S96.8- category that specify the affected structure.
• If the laterality (left or right foot) is documented, select a more specific code from the S96.81- series.