ICD-10 Coding for Right Distal Tibia Fracture(S82.841A, S82.841K)
Complete ICD-10-CM coding and documentation guide for Right Distal Tibia Fracture. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Distal Tibia 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 |
|---|---|---|---|
| S82.841A | Other fracture of lower end of right tibia, initial encounter for closed fracture | Use this code for initial encounters of closed fractures of the right distal tibia. |
|
| S82.841K | Other fracture of lower end of right tibia, subsequent encounter for fracture with nonunion | Use for subsequent encounters when the fracture has not healed and nonunion is confirmed. |
|
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 distal tibia fracture
Essential facts and insights about Right Distal Tibia Fracture
Primary ICD-10-CM Codes for right distal tibia fracture
Decision Criteria
documentation Criteria
- Documentation must specify 'distal' and 'right' for accurate coding.
Applicable To
- Closed fracture of right distal tibia
Excludes
- Fracture of shaft of tibia (S82.20-)
Clinical Validation Requirements
- X-ray or CT confirming fracture location in distal tibia
- Clinical documentation specifying 'distal' and 'right'
Code-Specific Risks
- Misclassification as a shaft fracture if 'distal' is not documented
Coding Notes
- Ensure documentation specifies 'distal' to avoid coding errors.
S82.841K - Other fracture of lower end of right tibia, subsequent encounter for fracture with nonunion
Use for subsequent encounters when the fracture has not healed and nonunion is confirmed.
Applicable To
- Nonunion of right distal tibia fracture
Excludes
- Malunion of fracture (M84.0-)
Clinical Validation Requirements
- CT or X-ray showing nonunion at fracture site
- Clinical documentation of nonunion status
Coding Notes
Nonunion must be confirmed by imaging.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Fracture of lateral malleolus of right fibula, initial encounter for closed fracture
S82.641ADifferential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Fracture of shaft of right tibia, initial encounter for closed fracture
S82.201AOther fracture of lower end of right tibia, subsequent encounter for fracture with routine healing
S82.841BDocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Right Distal Tibia Fracture to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S82.841A.
Impact
Clinical: May lead to incorrect treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential for claim denials due to unspecified codes.
Mitigation Strategy
Always document the side of the body affected., Use templates that prompt for laterality.
Impact
Reimbursement: Incorrect coding can lead to denied claims or incorrect DRG assignment., Compliance: Misclassification may result in compliance issues during audits., Data Quality: Impacts the accuracy of clinical data and patient records.
Mitigation Strategy
Ensure documentation specifies 'distal' to differentiate from shaft fractures.
Impact
Risk of audits due to non-specific fracture coding.
Mitigation Strategy
Use detailed templates and ensure imaging supports documentation.
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 Distal Tibia Fracture, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Distal Tibia Fracture
Use these documentation templates to ensure complete and accurate documentation for Right Distal Tibia Fracture. These templates include all required elements for proper coding and billing.
Initial Orthopedic Evaluation
Specialty: OrthopedicsRequired Elements
- Mechanism of injury
- Imaging findings
- Neurovascular status
- Fracture specifics (location, displacement)
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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