ICD-10 Coding for Fracture of Tibia(S82.121A)
Complete ICD-10-CM coding and documentation guide for Fracture of Tibia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Fracture of Tibia
S82.10-S82.9Primary Range
Fractures of the tibia
This range includes all types of tibial fractures, specifying location, laterality, and encounter type.
Key Information: ICD-10 code for tibia fracture
Essential facts and insights about Fracture of Tibia
Primary ICD-10-CM Code for fracture of tibia
Decision Criteria
clinical Criteria
- Imaging shows displaced fracture of lateral condyle.
documentation Criteria
- Documentation specifies closed fracture and initial encounter.
Applicable To
- Displaced fracture of lateral condyle of tibia
Excludes
- Stress fracture of tibia
- Pathological fracture of tibia
Clinical Validation Requirements
- Imaging confirmation of fracture displacement
- Clinical documentation of closed fracture
Code-Specific Risks
- Incorrect laterality documentation
- Missing 7th character for encounter type
Coding Notes
- Ensure documentation specifies displacement and laterality.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Stress fracture of right tibia
M84.361ADifferential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Fracture of medial malleolus of right tibia
S82.51xADocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Fracture of Tibia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S82.121A.
Impact
Clinical: Ambiguity in treatment planning., Regulatory: Non-compliance with documentation standards., Financial: Potential for claim denial due to lack of specificity.
Mitigation Strategy
Use templates for documentation, Ensure imaging reports are referenced
Impact
Reimbursement: Incorrect billing and potential claim denial., Compliance: Non-compliance with ICD-10 coding standards., Data Quality: Inaccurate patient records and data reporting.
Mitigation Strategy
Ensure the correct 7th character is used to indicate the encounter type (e.g., initial, subsequent).
Impact
Failure to document displacement can lead to incorrect coding.
Mitigation Strategy
Implement mandatory fields in EHR for displacement details.
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 Fracture of Tibia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Fracture of Tibia
Use these documentation templates to ensure complete and accurate documentation for Fracture of Tibia. These templates include all required elements for proper coding and billing.
Operative Note for ORIF Tibial Plateau
Specialty: Orthopedic SurgeryRequired Elements
- Preoperative diagnosis
- Operative findings
- Procedure details
- Postoperative plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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