ICD-10 Coding for Proximal Tibia Fracture(S82.121A, S82.141A)
Complete ICD-10-CM coding and documentation guide for Proximal Tibia Fracture. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Proximal Tibia Fracture
S82.1Primary Range
Fracture of upper end of tibia
This range includes specific codes for fractures of the proximal tibia, including lateral and medial condyle 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 |
|---|---|---|---|
| S82.121A | Displaced fracture of lateral condyle of right tibia, initial encounter for closed fracture | Use for initial encounter of displaced lateral condyle fracture of the right tibia. |
|
| S82.141A | Displaced fracture of medial condyle of right tibia, initial encounter for closed fracture | Use for initial encounter of displaced medial condyle fracture of the right tibia. |
|
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 tibia fracture
Essential facts and insights about Proximal Tibia Fracture
Primary ICD-10-CM Codes for proximal tibia fracture
Decision Criteria
clinical Criteria
- CT shows >3mm articular depression
documentation Criteria
- Surgical plan includes ORIF
Applicable To
- Displaced lateral condyle fracture
Clinical Validation Requirements
- CT-confirmed depression >3mm
- Joint instability
- ORIF planned
Code-Specific Risks
- Incorrect laterality documentation
- Missing displacement status
Coding Notes
- Ensure documentation specifies laterality and displacement.
S82.141A - Displaced fracture of medial condyle of right tibia, initial encounter for closed fracture
Use for initial encounter of displaced medial condyle fracture of the right tibia.
Applicable To
- Displaced medial condyle fracture
Excludes
- Fracture of shaft of tibia (S82.2)
- Physeal fracture of tibia (S89.0)
Clinical Validation Requirements
- Varus deformity
- Medial joint line tenderness
Coding Notes
Ensure documentation specifies laterality and displacement.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Internal derangement of knee
M23.-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 Proximal Tibia Fracture to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S82.121A.
Impact
Clinical: Inaccurate clinical assessment., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Always document displacement status in clinical notes., Review imaging reports for displacement details.
Impact
Reimbursement: Incorrect coding can lead to claim denials., Compliance: Non-compliance with coding standards., Data Quality: Inaccurate patient records.
Mitigation Strategy
Verify and document the correct side of the fracture.
Impact
Use of unspecified codes without supporting documentation.
Mitigation Strategy
Ensure all documentation includes specific details required for precise 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 Proximal Tibia Fracture, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Proximal Tibia Fracture
Use these documentation templates to ensure complete and accurate documentation for Proximal Tibia Fracture. These templates include all required elements for proper coding and billing.
Initial Encounter for Displaced Lateral Condyle Fracture
Specialty: OrthopedicsRequired Elements
- Mechanism of injury
- Imaging results
- Clinical findings
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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