ICD-10 Coding for Lateral Malleolus Fracture(S82.64XA, S82.61XA)
Complete ICD-10-CM coding and documentation guide for Lateral Malleolus Fracture. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Lateral Malleolus Fracture
S82.6Primary Range
Fracture of lateral malleolus
This range includes specific codes for fractures of the lateral malleolus, detailing laterality and displacement.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S82.64XA | Nondisplaced fracture of lateral malleolus of right fibula, initial encounter for closed fracture | Use for initial encounters of nondisplaced right lateral malleolus fractures. |
|
| S82.61XA | Displaced fracture of lateral malleolus of right fibula, initial encounter for closed fracture | Use for initial encounters of displaced right lateral malleolus fractures. |
|
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 nondisplaced right lateral malleolus fracture
Essential facts and insights about Lateral Malleolus Fracture
Primary ICD-10-CM Codes for lateral malleolus fracture
Decision Criteria
clinical Criteria
- X-ray shows no displacement
documentation Criteria
- Notes confirm closed fracture
Applicable To
- Nondisplaced fracture of right lateral malleolus
Excludes
- Bimalleolar fracture
- Trimalleolar fracture
Clinical Validation Requirements
- X-ray confirming nondisplacement
- Clinical notes specifying closed fracture
Code-Specific Risks
- Misclassification as displaced fracture
Coding Notes
- Ensure documentation specifies nondisplacement and laterality.
S82.61XA - Displaced fracture of lateral malleolus of right fibula, initial encounter for closed fracture
Use for initial encounters of displaced right lateral malleolus fractures.
Applicable To
- Displaced fracture of right lateral malleolus
Excludes
- Bimalleolar fracture
- Trimalleolar fracture
Clinical Validation Requirements
- CT/MRI showing displacement
- Clinical notes specifying closed fracture
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.
Fall on same level from slipping, tripping and stumbling
W00.0XXADifferential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Displaced fracture of lateral malleolus of right fibula, initial encounter for closed fracture
S82.61XANondisplaced fracture of lateral malleolus of right fibula, initial encounter for closed fracture
S82.64XADocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Lateral Malleolus Fracture to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S82.64XA.
Impact
Clinical: Inaccurate treatment planning., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Use standardized templates, Verify imaging reports
Impact
Reimbursement: Incorrect billing and potential claim denial., Compliance: Non-compliance with coding standards., Data Quality: Inaccurate patient records.
Mitigation Strategy
Verify documentation for correct side before coding.
Impact
Reimbursement: Potential underbilling or overbilling., Compliance: Non-compliance with coding standards., Data Quality: Inaccurate patient records.
Mitigation Strategy
Ensure documentation specifies lateral malleolus, not bimalleolar.
Impact
Misclassification of fracture type can lead to audit flags.
Mitigation Strategy
Implement regular training on fracture coding.
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 Lateral Malleolus Fracture, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Lateral Malleolus Fracture
Use these documentation templates to ensure complete and accurate documentation for Lateral Malleolus Fracture. These templates include all required elements for proper coding and billing.
Initial encounter for lateral malleolus fracture
Specialty: OrthopedicsRequired Elements
- Mechanism of injury
- Imaging findings
- Fracture type and laterality
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Lateral Malleolus Fracture? Ask your questions below.