ICD-10 Coding for Tibia and Fibula Fracture(S82.201A, S82.5-)
Complete ICD-10-CM coding and documentation guide for Tibia and Fibula Fracture. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Tibia and Fibula Fracture
S82.2-S82.6Primary Range
Fractures of the tibia and fibula
This range includes specific codes for fractures of the tibial shaft, lower end, medial malleolus, and lateral malleolus.
Stress fracture, tibia and fibula
Used for stress fractures of the tibia and fibula, confirmed by imaging.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S82.201A | Displaced fracture of shaft of right tibia, initial encounter for closed fracture | Use when there is a displaced fracture of the right tibial shaft without fibular involvement. |
|
| S82.5- | Fracture of medial malleolus | Use when there is a fracture of the medial malleolus, especially with tibia/fibula involvement. |
|
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 tibia fibula fracture
Essential facts and insights about Tibia and Fibula Fracture
Primary ICD-10-CM Codes for tibia fibula fracture
Decision Criteria
clinical Criteria
- Displaced fracture confirmed by imaging
documentation Criteria
- Laterality and displacement status documented
Applicable To
- Displaced fracture of right tibial shaft
Excludes
- Stress fracture of right tibia (M84.361A)
Clinical Validation Requirements
- X-ray showing displaced fracture of tibial shaft
Code-Specific Risks
- Ensure laterality is documented to avoid unspecified coding.
Coding Notes
- Ensure documentation specifies open vs. closed and laterality.
S82.5- - Fracture of medial malleolus
Use when there is a fracture of the medial malleolus, especially with tibia/fibula involvement.
Applicable To
- Fracture of medial malleolus with tibia/fibula involvement
Excludes
- Isolated fibular fracture (S82.4-)
Clinical Validation Requirements
- X-ray or CT showing fracture of medial malleolus
Coding Notes
Ensure documentation specifies involvement of the medial malleolus.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential 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 Tibia and Fibula Fracture to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S82.201A.
Impact
Clinical: Leads to incomplete patient records., Regulatory: Increases risk of audit issues., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Always document laterality in clinical notes., Use templates that prompt for laterality.
Impact
Reimbursement: May lead to lower DRG weights and reimbursement., Compliance: Increases risk of audit failures., Data Quality: Reduces accuracy of health records.
Mitigation Strategy
Always document and code laterality and fracture type (open/closed).
Impact
Using unspecified codes when specific details are available.
Mitigation Strategy
Ensure documentation includes all necessary details for specific coding.
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 Tibia and Fibula Fracture, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Tibia and Fibula Fracture
Use these documentation templates to ensure complete and accurate documentation for Tibia and Fibula Fracture. These templates include all required elements for proper coding and billing.
Emergency Department Visit for Tibial Fracture
Specialty: OrthopedicsRequired Elements
- Mechanism of injury
- Fracture location
- Laterality
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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