ICD-10 Coding for Medial Malleolus Fracture(S82.51XA, S82.55XG)
Complete ICD-10-CM coding and documentation guide for Medial Malleolus Fracture. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Medial Malleolus Fracture
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S82.51XA | Displaced fracture of right medial malleolus, initial encounter | Use when the fracture is displaced and involves the right medial malleolus during the initial encounter. |
|
| S82.55XG | Nondisplaced fracture of left medial malleolus, subsequent encounter with delayed healing | Use for subsequent encounters when healing is delayed. |
|
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: How do you code a medial malleolus fracture?
Essential facts and insights about Medial Malleolus Fracture
Primary ICD-10-CM Codes for medial malleolus fracture
Decision Criteria
clinical Criteria
- Presence of >2mm displacement on imaging
documentation Criteria
- Explicit mention of 'displaced' in clinical notes
Applicable To
- Displaced fracture of right medial malleolus
Excludes
- Nondisplaced fracture of right medial malleolus
Clinical Validation Requirements
- X-ray or CT showing >2mm displacement
- Clinical documentation of displacement
Code-Specific Risks
- Misclassification if displacement is not documented
Coding Notes
- Ensure documentation specifies displacement and laterality to avoid unspecified coding.
S82.55XG - Nondisplaced fracture of left medial malleolus, subsequent encounter with delayed healing
Use for subsequent encounters when healing is delayed.
Applicable To
- Nondisplaced fracture of left medial malleolus
Excludes
- Displaced fracture of left medial malleolus
Clinical Validation Requirements
- X-ray showing nondisplacement
- Clinical notes indicating delayed healing
Coding Notes
Ensure documentation reflects the healing status to select the correct 7th character.
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 Medial Malleolus Fracture to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S82.51XA.
Impact
Clinical: Inaccurate tracking of healing progress, Regulatory: Non-compliance with coding guidelines, Financial: Potential for incorrect billing and reimbursement
Mitigation Strategy
Regularly update clinical documentation with healing status, Review coding guidelines for 7th character usage
Impact
Reimbursement: Potential for reduced reimbursement due to lack of specificity., Compliance: Increased risk of audit due to unspecified coding., Data Quality: Decreased data quality affecting clinical decision-making.
Mitigation Strategy
Always specify laterality in the code selection.
Impact
Audits may target unspecified fracture codes.
Mitigation Strategy
Ensure all documentation specifies fracture details.
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 Medial Malleolus Fracture, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Medial Malleolus Fracture
Use these documentation templates to ensure complete and accurate documentation for Medial Malleolus Fracture. These templates include all required elements for proper coding and billing.
Initial encounter for displaced fracture
Specialty: OrthopedicsRequired Elements
- Patient history
- Mechanism of injury
- 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 Medial Malleolus Fracture? Ask your questions below.