ICD-10 Coding for Right Ankle Fracture(S82.61XA, S82.64XA)
Complete ICD-10-CM coding and documentation guide for Right Ankle Fracture. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Ankle Fracture
S82.60-S82.69Primary Range
Fracture of lower leg, including ankle
This range includes specific codes for fractures of the ankle, including lateral and medial malleolus 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 |
|---|---|---|---|
| S82.61XA | Displaced fracture of lateral malleolus of right fibula, initial encounter | Use when there is a confirmed displaced fracture of the right lateral malleolus. |
|
| S82.64XA | Nondisplaced fracture of lateral malleolus of right fibula, initial encounter | Use when there is a confirmed nondisplaced fracture of the right lateral malleolus. |
|
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 right ankle fracture
Essential facts and insights about Right Ankle Fracture
Primary ICD-10-CM Codes for right ankle fracture
Decision Criteria
clinical Criteria
- Presence of a displaced fracture on imaging
documentation Criteria
- Explicit mention of 'right' and 'displaced' in medical records
Applicable To
- Displaced fracture of right lateral malleolus
Excludes
- Fracture of medial malleolus
- Fracture of posterior malleolus
Clinical Validation Requirements
- Radiographic evidence of displaced fracture
- Clinical signs of acute trauma
Code-Specific Risks
- Ensure laterality is documented
- Differentiate from medial malleolus fractures
Coding Notes
- Ensure documentation specifies 'displaced' and 'right' for accurate coding.
S82.64XA - Nondisplaced fracture of lateral malleolus of right fibula, initial encounter
Use when there is a confirmed nondisplaced fracture of the right lateral malleolus.
Applicable To
- Nondisplaced fracture of right lateral malleolus
Excludes
- Displaced fracture of lateral malleolus
Clinical Validation Requirements
- Radiographic evidence of nondisplaced fracture
- Clinical signs of acute trauma
Coding Notes
Ensure documentation specifies 'nondisplaced' and 'right' for accurate coding.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Right Ankle Fracture to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S82.61XA.
Impact
Clinical: Potential for incorrect treatment planning, Regulatory: Non-compliance with coding standards, Financial: Denial of claims due to lack of specificity
Mitigation Strategy
Always specify laterality and displacement status, Review imaging and clinical notes for details
Impact
Reimbursement: Claims may be denied if laterality is unspecified., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate patient records and potential for incorrect treatment.
Mitigation Strategy
Ensure the medical record explicitly states 'right' for the fracture location.
Impact
Failure to document laterality can lead to audit issues.
Mitigation Strategy
Implement a checklist to ensure laterality is documented in all cases.
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 Right Ankle Fracture, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Ankle Fracture
Use these documentation templates to ensure complete and accurate documentation for Right Ankle Fracture. These templates include all required elements for proper coding and billing.
Initial evaluation of right ankle fracture
Specialty: OrthopedicsRequired Elements
- Patient history
- 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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