ICD-10 Coding for Fracture of Right Tibia(S82.121A, M84.361A)
Complete ICD-10-CM coding and documentation guide for Fracture of Right 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 Right Tibia
S82.1-S82.9Primary Range
Fractures of the tibia and fibula
This range includes all fractures related to the tibia and fibula, including specific types like condyle and shaft fractures.
Stress fractures
Includes stress fractures of the tibia, which may occur due to repetitive stress or underlying conditions like osteoporosis.
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 imaging confirms a displaced fracture of the lateral condyle of the right tibia. |
|
| M84.361A | Stress fracture, right tibia, initial encounter | Use for stress fractures of the right tibia, often due to repetitive stress or underlying conditions. |
|
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 displaced fracture of right tibia
Essential facts and insights about Fracture of Right Tibia
Primary ICD-10-CM Codes for fracture right tibia
Decision Criteria
clinical Criteria
- Imaging shows lateral condyle involvement with displacement.
documentation Criteria
- Record specifies 'displaced fracture of lateral condyle of right tibia'.
Applicable To
- Displaced lateral condyle fracture
Excludes
- Medial malleolus fracture (S82.5)
Clinical Validation Requirements
- CT or X-ray confirmation of lateral condyle involvement
- Documentation of displacement and laterality
Code-Specific Risks
- Incorrectly coding as a shaft fracture
- Omitting laterality
Coding Notes
- Ensure documentation specifies the condyle involvement and displacement.
M84.361A - Stress fracture, right tibia, initial encounter
Use for stress fractures of the right tibia, often due to repetitive stress or underlying conditions.
Applicable To
- Pathological fracture due to osteoporosis
Excludes
- Traumatic fractures (S82.-)
Clinical Validation Requirements
- History of minimal trauma or repetitive stress
- Imaging confirmation of stress fracture
Coding Notes
Ensure documentation reflects the nature of the stress fracture.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Fall from same level, initial encounter
W19.XXXADifferential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Displaced fracture of shaft of right tibia, initial encounter for closed fracture
S82.301ADocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Fracture of Right 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: May lead to incorrect treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential for denied claims.
Mitigation Strategy
Always include 'right' or 'left' in documentation., Review documentation for completeness.
Impact
Reimbursement: Incorrect coding may lead to improper DRG assignment., Compliance: May result in audit discrepancies., Data Quality: Affects clinical data accuracy.
Mitigation Strategy
Verify imaging to confirm fracture location before coding.
Impact
Inaccurate coding of tibial fractures can lead to audits.
Mitigation Strategy
Implement regular training on fracture coding and documentation.
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 Right Tibia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Fracture of Right Tibia
Use these documentation templates to ensure complete and accurate documentation for Fracture of Right Tibia. These templates include all required elements for proper coding and billing.
Post-operative documentation for ORIF
Specialty: OrthopedicsRequired Elements
- Preoperative diagnosis
- Procedure performed
- Implants used
- Postoperative plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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