ICD-10 Coding for Tibia Fracture(S82.121A, M84.361A)
Complete ICD-10-CM coding and documentation guide for Tibia Fracture. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Tibia Fracture
S82.10-S82.199Primary Range
Fractures of the upper end of tibia
This range includes specific codes for fractures of the tibial plateau and condyles, which are common in traumatic injuries.
Stress fracture of tibia and fibula
This range is used for stress fractures, often seen in athletes or patients with osteoporosis.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S82.121A | Displaced fracture of lateral condyle of right tibia, initial encounter for closed fracture | Use for initial encounters of displaced lateral condyle fractures of the right tibia. |
|
| M84.361A | Stress fracture, right tibia, initial encounter | Use for initial encounters of stress fractures of the right tibia. |
|
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 fracture
Essential facts and insights about Tibia Fracture
Primary ICD-10-CM Codes for tibia fracture
Decision Criteria
clinical Criteria
- Presence of displacement on imaging
documentation Criteria
- Clear documentation of closed fracture and initial encounter
Applicable To
- Displaced lateral condyle fracture
Excludes
- Stress fractures (M84.36-)
Clinical Validation Requirements
- X-ray or CT showing displacement
- Documentation of closed fracture
Code-Specific Risks
- Incorrect laterality
- Missing 7th character for encounter type
Coding Notes
- Ensure laterality and encounter type are documented.
M84.361A - Stress fracture, right tibia, initial encounter
Use for initial encounters of stress fractures of the right tibia.
Applicable To
- Stress fracture due to overuse
Excludes
- Traumatic fractures (S82.-)
Clinical Validation Requirements
- MRI or bone scan confirming stress fracture
- Documentation of overuse or repetitive stress
Coding Notes
Ensure documentation includes mechanism of injury and imaging results.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Personal history of (healed) fracture
Z87.81Differential 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 Fracture to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S82.121A.
Impact
Clinical: Can lead to incorrect treatment plans., Regulatory: Non-compliance with coding standards., Financial: Potential for claim denials.
Mitigation Strategy
Always document the side of the body affected., Use templates that prompt for laterality.
Impact
Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Non-compliance with coding specificity requirements., Data Quality: Decreases accuracy of health records.
Mitigation Strategy
Specify the condyle and laterality to use specific codes like S82.121A.
Impact
Risk of audits due to use of unspecified codes.
Mitigation Strategy
Use specific codes with 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 Tibia Fracture, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Tibia Fracture
Use these documentation templates to ensure complete and accurate documentation for Tibia Fracture. These templates include all required elements for proper coding and billing.
Initial encounter for displaced tibial fracture
Specialty: OrthopedicsRequired Elements
- Mechanism of injury
- Physical exam findings
- Imaging results
- Fracture classification
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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