ICD-10 Coding for Left Tibial Fracture(S82.221A)
Complete ICD-10-CM coding and documentation guide for Left Tibial Fracture. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Left Tibial Fracture
S82.20-S82.29Primary Range
Fracture of shaft of tibia
This range includes codes for fractures of the shaft of the tibia, specifying laterality and encounter type.
Fall-related external cause codes
These codes are used to specify the external cause of injury, such as falls.
Key Information: ICD-10 code for left tibial fracture
Essential facts and insights about Left Tibial Fracture
Primary ICD-10-CM Code for left tibial fracture
Decision Criteria
clinical Criteria
- Confirmed fracture via imaging
documentation Criteria
- Initial encounter documentation
Applicable To
- Closed displaced fracture of left tibial shaft
Excludes
- Open fracture of left tibia
Clinical Validation Requirements
- X-ray or CT confirming displacement and fracture location
- Clinical documentation of initial encounter
Code-Specific Risks
- Incorrect laterality documentation
- Missing encounter type
Coding Notes
- Ensure documentation specifies laterality, fracture type, and encounter phase.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Fall on same level from slipping
W11.XXXADifferential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Pathological fracture, right tibia
M84.461ADocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Left Tibial Fracture to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S82.221A.
Impact
Clinical: Ambiguity in treatment plans, Regulatory: Non-compliance with coding standards, Financial: Potential for claim denials
Mitigation Strategy
Standardize documentation templates, Regular training for staff
Impact
Reimbursement: Potential claim denials or reduced reimbursement., Compliance: Increased audit risk., Data Quality: Decreased accuracy in medical records.
Mitigation Strategy
Use specific codes like S82.221A with complete documentation.
Impact
Using unspecified codes increases audit risk.
Mitigation Strategy
Use specific codes with complete 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 Left Tibial Fracture, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Left Tibial Fracture
Use these documentation templates to ensure complete and accurate documentation for Left Tibial Fracture. These templates include all required elements for proper coding and billing.
Initial Encounter for Displaced Left Tibial Fracture
Specialty: OrthopedicsRequired Elements
- Patient history
- Physical examination
- Imaging results
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Left Tibial Fracture? Ask your questions below.