ICD-10 Coding for Fractured Tibia(S82.201A, S82.142A)
Complete ICD-10-CM coding and documentation guide for Fractured Tibia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Fractured Tibia
S82.2-S82.8Primary Range
Fracture of tibia, including shaft, lower end, and other specified parts
This range covers all types of tibial fractures, including shaft, plateau, and malleolus.
Pathological and stress fractures
Used for fractures due to underlying conditions like osteoporosis or stress.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S82.201A | Unspecified fracture of shaft of right tibia, initial encounter | Use when the fracture is unspecified in terms of displacement and laterality is right. |
|
| S82.142A | Displaced fracture of lateral condyle of left tibia, initial encounter | Use for displaced fractures of the lateral condyle of the left tibia. |
|
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 fractured tibia
Essential facts and insights about Fractured Tibia
Primary ICD-10-CM Codes for fractured tibia
Decision Criteria
clinical Criteria
- Presence of fracture confirmed by imaging
documentation Criteria
- Documentation of fracture type and laterality
Applicable To
- Fracture of tibial shaft
Excludes
- Pathological fracture of tibia (M84.46-)
Clinical Validation Requirements
- X-ray or CT confirming fracture
- Clinical documentation of mechanism of injury
Code-Specific Risks
- Risk of under-documentation if displacement is not specified
Coding Notes
- Ensure laterality and displacement are documented for precise coding.
S82.142A - Displaced fracture of lateral condyle of left tibia, initial encounter
Use for displaced fractures of the lateral condyle of the left tibia.
Applicable To
- Lateral tibial plateau fracture
Excludes
- Medial malleolus fracture (S82.5-)
Clinical Validation Requirements
- CT scan showing displacement
- Clinical notes specifying lateral condyle involvement
Coding Notes
Ensure documentation specifies the condyle and displacement.
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 Fractured Tibia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S82.201A.
Impact
Clinical: Potential for incorrect treatment, Regulatory: Non-compliance with coding guidelines, Financial: Denied claims or reduced reimbursement
Mitigation Strategy
Use templates that prompt for laterality, Cross-check with imaging reports
Impact
Reimbursement: May lead to incorrect DRG assignment and reimbursement, Compliance: Non-compliance with ICD-10 specificity requirements, Data Quality: Inaccurate clinical data affecting patient records
Mitigation Strategy
Ensure documentation specifies lateral or medial condyle involvement.
Impact
Audits may target lack of specificity in fracture documentation.
Mitigation Strategy
Use detailed templates and cross-reference 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 Fractured Tibia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Fractured Tibia
Use these documentation templates to ensure complete and accurate documentation for Fractured Tibia. These templates include all required elements for proper coding and billing.
Emergency Department Note for Tibial Fracture
Specialty: OrthopedicsRequired Elements
- Mechanism of injury
- Imaging results
- Fracture type and location
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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