ICD-10 Coding for Fracture of Tibial Plateau(S82.121A, S82.141A)
Complete ICD-10-CM coding and documentation guide for Fracture of Tibial Plateau. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Fracture of Tibial Plateau
S82.1-S82.2Primary Range
Fractures of upper end of tibia
This range includes specific codes for fractures of the tibial plateau, detailing laterality, displacement, and encounter type.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S82.121A | Displaced fracture of lateral condyle of right tibia, initial encounter for closed fracture | Use when documentation specifies a displaced fracture of the lateral condyle of the right tibia, closed, initial encounter. |
|
| S82.141A | Displaced fracture of medial condyle of right tibia, initial encounter for closed fracture | Use when documentation specifies a displaced fracture of the medial condyle of the right tibia, closed, initial encounter. |
|
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 tibial plateau fracture
Essential facts and insights about Fracture of Tibial Plateau
Primary ICD-10-CM Codes for fracture of tibial plateau
Decision Criteria
clinical Criteria
- CT/X-ray confirms split depression with ≥5mm depression
documentation Criteria
- Documentation specifies 'displaced', 'lateral condyle', 'right tibia', 'closed', 'initial encounter'
Applicable To
- Lateral condyle fracture
- Displaced
- Closed fracture
Excludes
- Fracture of tibial shaft
- Open fracture without Gustilo classification
Clinical Validation Requirements
- CT/X-ray showing ≥5mm articular depression
- Split depression morphology
Code-Specific Risks
- Incorrect coding if displacement or laterality is not specified
Coding Notes
- Ensure documentation specifies displacement and laterality to avoid queries.
S82.141A - Displaced fracture of medial condyle of right tibia, initial encounter for closed fracture
Use when documentation specifies a displaced fracture of the medial condyle of the right tibia, closed, initial encounter.
Applicable To
- Medial condyle fracture
- Displaced
- Closed fracture
Excludes
- Fracture of tibial shaft
- Open fracture without Gustilo classification
Clinical Validation Requirements
- Medial condyle involvement with coronal plane fracture line
Coding Notes
Ensure documentation specifies displacement and laterality to avoid queries.
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 Fracture of Tibial Plateau to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S82.121A.
Impact
Clinical: Leads to incorrect treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Review imaging before documentation, Use structured templates
Impact
Reimbursement: Incorrect coding can lead to lower reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Poor data quality affecting clinical records.
Mitigation Strategy
Ensure documentation specifies laterality and displacement status.
Impact
Lack of specificity can lead to audit flags.
Mitigation Strategy
Ensure all documentation includes specific fracture 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 Tibial Plateau, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Fracture of Tibial Plateau
Use these documentation templates to ensure complete and accurate documentation for Fracture of Tibial Plateau. These templates include all required elements for proper coding and billing.
Orthopedic Progress Note
Specialty: OrthopedicsRequired Elements
- Diagnosis
- Imaging
- Management
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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