ICD-10 Coding for Tibial Fracture(S82.201A, S82.201B)
Complete ICD-10-CM coding and documentation guide for Tibial Fracture. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Tibial Fracture
S82.20-S82.29Primary Range
Fracture of shaft of tibia
This range covers fractures of the tibial shaft, which are common and require specific coding based on the fracture's characteristics.
Fracture of lower end of tibia
This range is used when the fracture involves the distal end of the tibia, often near the ankle joint.
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 | Unspecified fracture of shaft of right tibia, initial encounter for closed fracture | Use for initial encounters where the fracture is closed and involves the shaft of the right tibia. |
|
| S82.201B | Unspecified fracture of shaft of right tibia, initial encounter for open fracture | Use for initial encounters where the fracture is open and involves the shaft 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 tibial fracture
Essential facts and insights about Tibial Fracture
Primary ICD-10-CM Codes for tibial fracture
Decision Criteria
clinical Criteria
- Fracture line visible on X-ray in the shaft of the tibia
documentation Criteria
- Documentation must specify laterality and encounter type
Applicable To
- Closed fracture of right tibial shaft
Excludes
- Fracture of tibial plateau (S82.14-)
Clinical Validation Requirements
- X-ray showing fracture line in the shaft of the tibia
- Physical exam indicating swelling and tenderness over the tibial shaft
Code-Specific Risks
- Ensure laterality and encounter type are specified to avoid unspecified coding.
Coding Notes
- Ensure that the fracture type (open vs closed) and encounter type are clearly documented.
S82.201B - Unspecified fracture of shaft of right tibia, initial encounter for open fracture
Use for initial encounters where the fracture is open and involves the shaft of the right tibia.
Applicable To
- Open fracture of right tibial shaft
Excludes
- Fracture of tibial plateau (S82.14-)
Clinical Validation Requirements
- X-ray showing fracture line in the shaft of the tibia
- Clinical documentation of open wound with bone exposure
Coding Notes
Ensure that the fracture type (open vs closed) and encounter type are clearly documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Periprosthetic fracture around internal prosthetic right knee joint, initial encounter
M97.1XADocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Tibial 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: Inaccurate treatment planning and follow-up care., Regulatory: Non-compliance with coding standards., Financial: Potential for denied claims or reduced reimbursement.
Mitigation Strategy
Always document the Gustilo-Anderson classification for open fractures., Include wound size and bone exposure details.
Impact
Reimbursement: Incorrect coding can lead to denied claims or reduced reimbursement., Compliance: Failure to comply with coding guidelines can result in audits., Data Quality: Unspecified codes reduce the accuracy of health data.
Mitigation Strategy
Always specify the encounter type using the appropriate 7th character (e.g., A for initial, D for subsequent).
Impact
Using unspecified codes can trigger audits due to lack of specificity.
Mitigation Strategy
Ensure all documentation includes specific details about the fracture type, location, and encounter.
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 Tibial Fracture, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Tibial Fracture
Use these documentation templates to ensure complete and accurate documentation for Tibial Fracture. These templates include all required elements for proper coding and billing.
Initial encounter for tibial shaft fracture
Specialty: OrthopedicsRequired Elements
- Patient history
- Physical examination findings
- Imaging results
- Fracture classification
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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