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ICD-10 Coding for Left Foot Fracture(S92.3XXA, S92.355A)

Complete ICD-10-CM coding and documentation guide for Left Foot Fracture. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Fracture of the left footLeft foot bone fracture

Related ICD-10 Code Ranges

Complete code families applicable to Left Foot Fracture

S92.3XXA-S92.9XXAPrimary Range

Fractures of foot, except ankle

This range includes specific codes for fractures of the metatarsals, phalanges, and other bones of the foot.

Periprosthetic fracture around internal prosthetic joint

Used when a fracture occurs around a prosthetic joint, requiring additional coding for the prosthesis.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
S92.3XXAFracture of metatarsal bone(s), left foot, initial encounterUse for any confirmed fracture of the metatarsal bones in the left foot during the initial encounter.
  • X-ray confirmation of fracture
  • Physical exam showing tenderness and swelling
S92.355ADisplaced fracture of fifth metatarsal bone, left foot, initial encounterUse for a confirmed displaced fracture of the fifth metatarsal, especially at the metaphyseal-diaphyseal junction.
  • X-ray showing fracture at the base of the fifth metatarsal
  • History of acute inversion injury

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 left foot fracture

Essential facts and insights about Left Foot Fracture

The ICD-10 code for a left foot fracture depends on the specific bone and fracture type, such as S92.3XXA for metatarsal fractures.

Primary ICD-10-CM Codes for left foot fracture

Fracture of metatarsal bone(s), left foot, initial encounter
Non-billable Code

Decision Criteria

clinical Criteria

  • Confirmed fracture via imaging

documentation Criteria

  • Specification of laterality and encounter type

Applicable To

  • Fracture of any metatarsal bone in the left foot

Excludes

  • Stress fracture of metatarsal (M84.375A)

Clinical Validation Requirements

  • X-ray confirmation of fracture
  • Physical exam showing tenderness and swelling

Code-Specific Risks

  • Ensure laterality is specified to avoid denials.

Coding Notes

  • Ensure documentation specifies the exact metatarsal involved and whether the fracture is open or closed.

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Unspecified fall, initial encounter

W19.XXXA
Use to describe the external cause of the fracture if due to a fall.

Home injury location

Y92.0
Use to specify the location of the injury if it occurred at home.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Stress fracture, left foot

M84.375A
Use when the fracture is due to repetitive stress rather than acute trauma.

Fracture of other metatarsal bone, left foot

S92.36XA
Use when the fracture is not at the base of the fifth metatarsal.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Left Foot Fracture to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S92.3XXA.

Impact

Clinical: Leads to incorrect treatment plans, Regulatory: Non-compliance with coding guidelines, Financial: Potential for claim denials

Mitigation Strategy

Always include encounter type in notes, Use templates to ensure completeness

Impact

Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Increases risk of audit due to lack of specificity., Data Quality: Reduces the accuracy of clinical data.

Mitigation Strategy

Always specify the exact bone and laterality to use a more specific code.

Impact

High risk of audit when using unspecified codes without justification.

Mitigation Strategy

Always document specific fracture details and use the most specific code available.

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 Left Foot Fracture, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Left Foot Fracture

Use these documentation templates to ensure complete and accurate documentation for Left Foot Fracture. These templates include all required elements for proper coding and billing.

Orthopedic consultation for foot fracture

Specialty: Orthopedics

Required Elements

  • Patient history
  • Physical examination findings
  • Imaging results
  • Assessment and plan

Example Documentation

Patient presents with pain in the left foot after a fall. X-ray confirms a displaced fracture of the fifth metatarsal. Plan includes immobilization and follow-up in two weeks.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Foot fracture, left.
Good Documentation Example
Displaced fracture of the fifth metatarsal, left foot, initial encounter. Caused by fall from ladder.
Explanation
The good example provides specific details about the fracture and the cause, which are necessary for accurate coding.

Need help with ICD-10 coding for Left Foot Fracture? Ask your questions below.

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