ICD-10 Coding for Right Foot Trauma(S90.31XA, S92.301A)
Complete ICD-10-CM coding and documentation guide for Right Foot Trauma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Foot Trauma
S90-S99Primary Range
Injuries to the ankle and foot
This range includes all injuries specific to the ankle and foot, covering fractures, contusions, and other trauma.
Slipping, tripping, stumbling and falls
This range is used to code the external cause of injury, such as falls, which are common mechanisms for foot trauma.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S90.31XA | Contusion of right foot, initial encounter | Use when there is a contusion confirmed by clinical examination without fracture. |
|
| S92.301A | Fracture of metatarsal bone, right foot, initial encounter | Use when a fracture is confirmed by imaging. |
|
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 foot trauma
Essential facts and insights about Right Foot Trauma
Primary ICD-10-CM Codes for right foot trauma
Decision Criteria
clinical Criteria
- Presence of bruising and swelling without fracture
Applicable To
- Bruising of right foot
Excludes
- Fracture of foot
Clinical Validation Requirements
- Localized bruising and swelling without fracture on X-ray
Code-Specific Risks
- Ensure no fracture is present before using this code.
Coding Notes
- Ensure documentation specifies the absence of fracture.
S92.301A - Fracture of metatarsal bone, right foot, initial encounter
Use when a fracture is confirmed by imaging.
Applicable To
- Fracture of any metatarsal bone in the right foot
Excludes
- Contusion of foot
Clinical Validation Requirements
- Radiograph showing fracture line
Coding Notes
Document the specific bone fractured and the type of fracture.
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 Foot Trauma to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S90.31XA.
Impact
Clinical: May lead to inadequate treatment planning., Regulatory: Increases risk of audit failure., Financial: Potential for denied claims due to lack of specificity.
Mitigation Strategy
Always document specific findings and imaging results., Use templates to ensure comprehensive documentation.
Impact
Reimbursement: May lead to reduced reimbursement rates., Compliance: Increases risk of audit and non-compliance., Data Quality: Decreases the accuracy of clinical data.
Mitigation Strategy
Always use the most specific code available based on clinical documentation.
Impact
High risk of audit if unspecified codes are used without justification.
Mitigation Strategy
Use specific codes supported by detailed 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 Foot Trauma, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Foot Trauma
Use these documentation templates to ensure complete and accurate documentation for Right Foot Trauma. These templates include all required elements for proper coding and billing.
Initial evaluation of right foot trauma
Specialty: Emergency MedicineRequired Elements
- 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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