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ICD-10 Coding for Stress Fracture of the Second Toe(M84.377A, M84.378D)

Complete ICD-10-CM coding and documentation guide for Stress Fracture of the Second Toe. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Second Toe Stress FractureStress Fracture of Second Phalanx

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Related ICD-10 Code Ranges

Complete code families applicable to Stress Fracture of the Second Toe

M84.37-Primary Range

Stress fracture, toe(s)

This range covers stress fractures specifically in the toes, including the second toe.

S92.5-

Fracture of toe, traumatic

This range is for traumatic fractures of the toes, not applicable to stress fractures.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
M84.377AStress fracture, right toe(s), initial encounterUse for initial encounter of a stress fracture in the right second toe confirmed by imaging.
  • MRI or bone scan confirming stress fracture
  • Absence of acute trauma history
M84.378DStress fracture, left toe(s), subsequent encounterUse for follow-up visits after initial treatment of a stress fracture in the left second toe.
  • Follow-up imaging showing healing progress
  • Documentation of treatment plan

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 stress fracture second toe

Essential facts and insights about Stress Fracture of the Second Toe

The ICD-10 code for a stress fracture of the second toe is M84.377A for the right toe and M84.378D for the left toe.

Primary ICD-10-CM Codes for stress fracture second toe

M84.377A
Stress fracture, right toe(s), initial encounter
Billable Code

Decision Criteria

clinical Criteria

  • MRI confirms stress fracture without trauma

documentation Criteria

  • Documented absence of trauma and overuse history

Applicable To

  • Stress fracture of right second toe

Excludes

  • Traumatic fracture of toe (S92.5-)

Clinical Validation Requirements

  • MRI or bone scan confirming stress fracture
  • Absence of acute trauma history

Code-Specific Risks

  • Incorrectly coding as traumatic fracture
  • Omitting laterality

Coding Notes

  • Ensure imaging confirms diagnosis and document absence of trauma.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Other specified disorders of bone density

M85.8
Use if osteoporosis or osteopenia contributes to fracture risk.

Personal history of stress fracture

Z87.312
Use for patients with a history of stress fractures.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Traumatic fracture of toe

S92.5-
Use S92.5- if the fracture is due to an acute traumatic event.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Stress Fracture of the Second Toe to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M84.377A.

Impact

Clinical: Affects treatment planning and monitoring., Regulatory: Non-compliance with coding specificity requirements., Financial: Potential for claim denials due to unspecified codes.

Mitigation Strategy

Always specify right or left in documentation., Verify imaging reports for laterality.

Impact

Reimbursement: Incorrect coding can lead to denied claims., Compliance: Misclassification affects compliance with coding standards., Data Quality: Impacts the accuracy of patient records and data analysis.

Mitigation Strategy

Ensure documentation specifies absence of trauma and confirms diagnosis with imaging.

Impact

Lack of imaging confirmation can lead to coding errors.

Mitigation Strategy

Require imaging reports for all stress fracture diagnoses.

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 Stress Fracture of the Second Toe, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Stress Fracture of the Second Toe

Use these documentation templates to ensure complete and accurate documentation for Stress Fracture of the Second Toe. These templates include all required elements for proper coding and billing.

Initial Diagnosis of Stress Fracture

Specialty: Podiatry

Required Elements

  • Patient history of overuse
  • Imaging results confirming stress fracture
  • Absence of trauma

Example Documentation

Patient presents with right second toe pain. MRI confirms stress fracture. No trauma reported.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient has toe pain.
Good Documentation Example
Patient reports right second toe pain. MRI confirms stress fracture. No trauma.
Explanation
The good example includes specific location, imaging confirmation, and absence of trauma.

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