L23.9 - Allergic contact dermatitis, unspecified cause

Clinical Definition

A sprain of the calcaneofibular ligament (CFL) is an injury where this lateral ankle ligament is stretched or partially torn. The CFL connects the fibula to the calcaneus bone and helps stabilize the lateral ankle joint.

Documentation Requirements

• Laterality (right vs. left ankle)

• Severity/grade of sprain:

  • Grade 1: Mild stretching

  • Grade 2: Partial tear

  • Grade 3: Complete rupture

• Initial vs. subsequent encounter

• Healing status (routine, delayed, nonunion)

• Trauma mechanism/cause

• Active problems contributing to the injury

• Associated symptoms

Common Synonyms

• Outer ankle ligament injury

• Lateral ankle sprain

• "Rolled ankle" (patient term)

• Outside ankle strain

Coding Conflicts

Excludes1:

• Achilles tendon sprain

• Ankle dislocation without sprain

• Deltoid ligament sprain

Excludes2:

• Peroneal tendon strain

• Ankle arthritis

• Tarsal tunnel syndrome

Scribing.io Automation

Our AI scribe automatically:

• Detects anatomical terms ("calcaneofibular," "lateral ankle")

• Identifies injury descriptors ("sprain," "tear," "rupture")

• Maps laterality mentions

• Flags severity terms

• Links mechanism of injury to appropriate E-codes

• Distinguishes between initial and follow-up care

Remember to verbally specify grade and laterality during dictation for optimal documentation accuracy.