ICD-10 Coding for Right Calcaneal Fracture(S92.001A, S92.011A)
Complete ICD-10-CM coding and documentation guide for Right Calcaneal Fracture. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Calcaneal Fracture
S92.0Primary Range
Fracture of calcaneus
This range includes all codes related to fractures of the calcaneus, specifying laterality and fracture type.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S92.001A | Unspecified closed fracture of right calcaneus, initial encounter | Use when the fracture is closed and unspecified in terms of displacement. |
|
| S92.011A | Displaced closed fracture of right calcaneal body, initial encounter | Use when the fracture is displaced and involves the calcaneal body. |
|
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 calcaneal fracture
Essential facts and insights about Right Calcaneal Fracture
Primary ICD-10-CM Codes for right calcaneal fracture
Decision Criteria
documentation Criteria
- Document laterality and encounter type clearly.
Applicable To
- Closed fracture of right calcaneus
Excludes
- Open fracture of right calcaneus
Clinical Validation Requirements
- X-ray showing fracture without displacement
- Clinical note indicating right heel pain after trauma
Code-Specific Risks
- Risk of under-coding if displacement is present but not documented.
Coding Notes
- Ensure laterality and encounter type are documented.
S92.011A - Displaced closed fracture of right calcaneal body, initial encounter
Use when the fracture is displaced and involves the calcaneal body.
Applicable To
- Displaced fracture of right calcaneal body
Excludes
- Nondisplaced fracture of right calcaneus
Clinical Validation Requirements
- CT showing displacement >2mm
- Bohler’s angle <20°
Coding Notes
Document displacement and specific fracture location.
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 Calcaneal Fracture to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S92.001A.
Impact
Clinical: May lead to incorrect treatment., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Always include laterality in the clinical notes.
Impact
Reimbursement: May result in lower reimbursement rates., Compliance: Increases risk of audits due to lack of specificity., Data Quality: Leads to inaccurate clinical data recording.
Mitigation Strategy
Ensure documentation specifies displacement and fracture type.
Impact
High audit risk for using unspecified codes in trauma cases.
Mitigation Strategy
Train staff to document specific 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 Right Calcaneal Fracture, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Calcaneal Fracture
Use these documentation templates to ensure complete and accurate documentation for Right Calcaneal Fracture. These templates include all required elements for proper coding and billing.
Initial Evaluation of Right Calcaneal Fracture
Specialty: OrthopedicsRequired Elements
- Mechanism of injury
- Imaging findings
- Neurovascular status
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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