ICD-10 Coding for Bimalleolar Ankle Fracture(S82.841A, S82.842A)
Complete ICD-10-CM coding and documentation guide for Bimalleolar Ankle Fracture. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bimalleolar Ankle Fracture
S82.84-S82.85Primary Range
Fracture of the lower leg, including ankle
This range includes codes for bimalleolar fractures, specifying laterality and displacement.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S82.841A | Displaced bimalleolar fracture of right ankle, initial encounter | Use when both medial and lateral malleoli are fractured and displaced on the right ankle. |
|
| S82.842A | Displaced bimalleolar fracture of left ankle, initial encounter | Use when both medial and lateral malleoli are fractured and displaced on the left ankle. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for bimalleolar ankle fracture
Essential facts and insights about Bimalleolar Ankle Fracture
Primary ICD-10-CM Codes for bimalleolar ankle fracture
Decision Criteria
clinical Criteria
- Presence of fractures in both medial and lateral malleoli
documentation Criteria
- Explicit mention of displacement and laterality
Applicable To
- Displaced fracture of both medial and lateral malleoli
Excludes
- Trimalleolar fracture (S82.83XA)
Clinical Validation Requirements
- X-ray confirmation of fractures in both medial and lateral malleoli
- Clinical documentation of displacement
Code-Specific Risks
- Incorrectly coding as trimalleolar if posterior malleolus is not involved
Coding Notes
- Ensure documentation specifies both malleoli are fractured and displaced.
S82.842A - Displaced bimalleolar fracture of left ankle, initial encounter
Use when both medial and lateral malleoli are fractured and displaced on the left ankle.
Applicable To
- Displaced fracture of both medial and lateral malleoli
Excludes
- Trimalleolar fracture (S82.83XA)
Clinical Validation Requirements
- X-ray confirmation of fractures in both medial and lateral malleoli
- Clinical documentation of displacement
Coding Notes
Ensure documentation specifies both malleoli are fractured and displaced.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Application of external fixation device
20690Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Trimalleolar fracture of ankle
S82.83XADocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Bimalleolar Ankle Fracture to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S82.841A.
Impact
Clinical: Inaccurate treatment records., Regulatory: Potential audit issues., Financial: Denials or reduced reimbursement.
Mitigation Strategy
Thorough review of imaging before documentation., Use of standardized templates.
Impact
Reimbursement: Incorrect coding may lead to denials or reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Ensure both malleoli are fractured before using 27814.
Impact
Inadequate documentation of fracture specifics can lead to audit flags.
Mitigation Strategy
Use detailed templates and cross-check with imaging.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Bimalleolar Ankle Fracture, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bimalleolar Ankle Fracture
Use these documentation templates to ensure complete and accurate documentation for Bimalleolar Ankle Fracture. These templates include all required elements for proper coding and billing.
Operative Note for ORIF
Specialty: Orthopedic SurgeryRequired Elements
- Preoperative diagnosis
- Postoperative diagnosis
- Procedure details
- Implants used
- Intraoperative findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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