ICD-10 Coding for Proximal Fibula Fracture(S82.41xA, S82.42xA)
Complete ICD-10-CM coding and documentation guide for Proximal Fibula Fracture. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Proximal Fibula Fracture
S82.41-S82.42Primary Range
Fracture of proximal fibula
This range includes codes for fractures of the proximal fibula, specifying laterality and encounter type.
Sprain and strain of ankle
Relevant for coding associated ankle injuries, such as in Maisonneuve fractures.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S82.41xA | Fracture of proximal right fibula, initial encounter | Use for initial encounter of a closed fracture of the proximal right fibula. |
|
| S82.42xA | Fracture of proximal left fibula, initial encounter | Use for initial encounter of a closed fracture of the proximal left fibula. |
|
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 proximal fibula fracture
Essential facts and insights about Proximal Fibula Fracture
Primary ICD-10-CM Codes for proximal fibula fracture
Decision Criteria
clinical Criteria
- Presence of fracture confirmed by imaging
documentation Criteria
- Detailed description of fracture including laterality and type
Applicable To
- Closed fracture of proximal right fibula
- Nondisplaced fracture of proximal right fibula
Excludes
- Fracture of distal fibula
Clinical Validation Requirements
- X-ray or CT confirmation of fracture
- Clinical signs such as localized tenderness and swelling
Code-Specific Risks
- Incorrect laterality documentation
- Failure to specify fracture type (open vs. closed)
Coding Notes
- Ensure documentation specifies 'proximal' and laterality to avoid unspecified coding.
S82.42xA - Fracture of proximal left fibula, initial encounter
Use for initial encounter of a closed fracture of the proximal left fibula.
Applicable To
- Closed fracture of proximal left fibula
- Nondisplaced fracture of proximal left fibula
Excludes
- Fracture of distal fibula
Clinical Validation Requirements
- X-ray or CT confirmation of fracture
- Clinical signs such as localized tenderness and swelling
Coding Notes
Ensure documentation specifies 'proximal' and laterality to avoid unspecified coding.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Personal history of fracture
Z87.81Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Fracture of tibia shaft
S82.3xxADocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Proximal Fibula Fracture to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S82.41xA.
Impact
Clinical: May lead to incorrect treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential for claim denials or reduced reimbursement.
Mitigation Strategy
Always include laterality in the documentation.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data for clinical and research purposes.
Mitigation Strategy
Specify 'proximal' and laterality in documentation.
Impact
Using unspecified codes increases audit risk.
Mitigation Strategy
Ensure documentation specifies 'proximal' and laterality.
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 Proximal Fibula Fracture, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Proximal Fibula Fracture
Use these documentation templates to ensure complete and accurate documentation for Proximal Fibula Fracture. These templates include all required elements for proper coding and billing.
Initial encounter for proximal fibula fracture
Specialty: OrthopedicsRequired Elements
- Patient history
- Mechanism of injury
- Physical examination findings
- Imaging results
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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