ICD-10 Coding for Distal Tibia Fracture(S82.84-, S82.87-)
Complete ICD-10-CM coding and documentation guide for Distal Tibia Fracture. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Distal Tibia Fracture
S82.84-S82.87Primary Range
Fractures of the distal tibia, including pilon fractures
This range includes codes for distal tibia fractures, both intra-articular (pilon) and extra-articular.
Fractures involving the medial malleolus and distal fibula
This range is relevant for fractures that involve the distal tibia and fibula, commonly seen in bimalleolar or trimalleolar fractures.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S82.84- | Fracture of distal tibial shaft, extra-articular | Use for non-pilon distal tibia fractures that do not involve the articular surface. |
|
| S82.87- | Pilon fracture of the distal tibia | Use for fractures involving the tibial plafond with articular surface disruption. |
|
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 distal tibia fracture
Essential facts and insights about Distal Tibia Fracture
Primary ICD-10-CM Codes for distal tibia fracture
Decision Criteria
clinical Criteria
- Fracture is extra-articular and does not involve the tibial plafond.
documentation Criteria
- Laterality and encounter type must be documented.
Applicable To
- Metaphyseal fracture not involving the plafond
Excludes
- Pilon fracture (S82.87-)
Clinical Validation Requirements
- X-ray or CT showing fracture line distal to the tibial shaft
- Clinical documentation of fracture type and displacement
Code-Specific Risks
- Misclassification as pilon fracture
- Omission of laterality
Coding Notes
- Ensure documentation specifies fracture type and any associated injuries.
S82.87- - Pilon fracture of the distal tibia
Use for fractures involving the tibial plafond with articular surface disruption.
Applicable To
- Fracture involving the weight-bearing surface of the tibia
Excludes
- Fracture of distal tibial shaft, extra-articular (S82.84-)
Clinical Validation Requirements
- CT scan confirming intra-articular involvement
- Surgical notes detailing articular surface involvement
Coding Notes
Ensure detailed documentation of fracture characteristics and associated injuries.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Distal Tibia Fracture to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S82.84-.
Impact
Clinical: Can lead to incorrect treatment planning., Regulatory: Non-compliance with coding guidelines., Financial: Potential for denied claims due to incomplete documentation.
Mitigation Strategy
Always document laterality in clinical notes., Use templates that prompt for laterality.
Impact
Reimbursement: Incorrect coding may lead to improper DRG assignment., Compliance: Misclassification can trigger audits., Data Quality: Affects clinical data accuracy and patient records.
Mitigation Strategy
Verify imaging and surgical reports for articular involvement.
Impact
Incorrect classification of distal tibia fractures as either pilon or extra-articular.
Mitigation Strategy
Use imaging and detailed clinical documentation to accurately classify fractures.
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 Distal Tibia Fracture, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Distal Tibia Fracture
Use these documentation templates to ensure complete and accurate documentation for Distal Tibia Fracture. These templates include all required elements for proper coding and billing.
Initial Evaluation of Distal Tibia Fracture
Specialty: OrthopedicsRequired Elements
- Fracture type and location
- Laterality
- Displacement and comminution
- Associated injuries
- Imaging findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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