ICD-10 Coding for Right Tibia Fracture(S82.221A, M84.361A)
Complete ICD-10-CM coding and documentation guide for Right 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 Tibia Fracture
S82.20-S82.29Primary Range
Fracture of tibia
This range includes codes for fractures of the tibia, specifying laterality and fracture type.
Stress fracture
This range includes codes for stress fractures, which may apply if the fracture is due to repetitive stress.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S82.221A | Displaced fracture of shaft of right tibia, initial encounter for closed fracture | Use for initial encounters of displaced fractures of the right tibial shaft. |
|
| M84.361A | Stress fracture, right tibia, initial encounter | Use when a stress fracture is confirmed by imaging and history. |
|
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 tibia fracture
Essential facts and insights about Right Tibia Fracture
Primary ICD-10-CM Codes for right tibia fracture
Decision Criteria
clinical Criteria
- Displacement >2mm on imaging
documentation Criteria
- Initial encounter documented
Applicable To
- Displaced fracture of right tibial shaft
Excludes
- Open fracture of right tibial shaft
Clinical Validation Requirements
- Imaging showing displacement >2mm
- Documentation of initial encounter
Code-Specific Risks
- Ensure documentation specifies 'displaced' and 'closed'.
Coding Notes
- Ensure laterality and encounter type are documented.
M84.361A - Stress fracture, right tibia, initial encounter
Use when a stress fracture is confirmed by imaging and history.
Applicable To
- Stress fracture of right tibia
Excludes
- Pathological fracture due to underlying disease
Clinical Validation Requirements
- MRI confirmation of stress fracture
- History of repetitive stress activity
Coding Notes
Document repetitive activity leading to fracture.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Stress fracture, right tibia, initial encounter
M84.361ADifferential 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 Right Tibia Fracture to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S82.221A.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials or reduced reimbursement.
Mitigation Strategy
Always document specifics such as laterality and displacement., Use the most specific code available.
Impact
Reimbursement: Claims may be denied or delayed., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate patient records.
Mitigation Strategy
Always specify 'right' or 'left' in documentation.
Impact
Lack of specific details in fracture documentation can lead to audit issues.
Mitigation Strategy
Implement thorough documentation practices including laterality and encounter type.
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 Tibia Fracture, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Tibia Fracture
Use these documentation templates to ensure complete and accurate documentation for Right Tibia Fracture. These templates include all required elements for proper coding and billing.
Initial Encounter for Right Tibial Shaft Fracture
Specialty: OrthopedicsRequired Elements
- Patient history
- Imaging results
- Fracture specifics
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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