ICD-10 Coding for Tibial Plateau Fracture(S82.121A)
Complete ICD-10-CM coding and documentation guide for Tibial Plateau Fracture. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Tibial Plateau Fracture
S82.1Primary Range
Fracture of upper end of tibia
This range includes all tibial plateau fractures, specifying laterality, displacement, and episode of care.
Key Information: ICD-10 code for right tibial plateau fracture
Essential facts and insights about Tibial Plateau Fracture
Primary ICD-10-CM Code for tibial plateau fracture
Decision Criteria
clinical Criteria
- Confirmed lateral condyle fracture with displacement
documentation Criteria
- Documentation of initial encounter and closed fracture
Applicable To
- Displaced lateral condyle fracture of right tibia
Excludes
- Fracture of tibial shaft
- Fracture of distal tibia
Clinical Validation Requirements
- Imaging confirming lateral condyle involvement
- Documentation of displacement and laterality
Code-Specific Risks
- Incorrectly defaulting to displaced if not specified
- Missing laterality documentation
Coding Notes
- Ensure documentation specifies displacement, laterality, and episode of care.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Derangement of meniscus due to old tear or injury
M23.2Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Fracture of shaft of tibia
S82.2Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Tibial Plateau 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: Ambiguity in treatment planning and follow-up care., Regulatory: Non-compliance with ICD-10 coding standards., Financial: Potential for denied claims due to incomplete documentation.
Mitigation Strategy
Use standardized templates that require laterality., Educate providers on the importance of complete documentation.
Impact
Reimbursement: May lead to incorrect DRG assignment and reimbursement., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate clinical data affecting patient care and outcomes.
Mitigation Strategy
Always document whether the fracture is displaced or non-displaced.
Impact
Failure to document displacement status can lead to incorrect coding.
Mitigation Strategy
Implement mandatory fields in EHR for displacement status.
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 Plateau Fracture, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Tibial Plateau Fracture
Use these documentation templates to ensure complete and accurate documentation for Tibial Plateau Fracture. These templates include all required elements for proper coding and billing.
Initial Encounter for Displaced Lateral Tibial Plateau Fracture
Specialty: OrthopedicsRequired Elements
- Fracture location and type
- Displacement status
- Laterality
- Episode of care
- Associated injuries
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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