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S92.009A
ICD-10-CM
Calcaneus Fracture

Understanding Calcaneus Fracture (Heel Bone Fracture, Os Calcis Fracture) diagnosis, treatment, and recovery. Find information on clinical documentation, medical coding, ICD-10 codes, healthcare guidelines, and best practices for managing a Calcaneus Fracture. Learn about postoperative care, physical therapy, and complications associated with a Heel Bone Fracture. This resource provides valuable insights for healthcare professionals, coders, and patients seeking information on Os Calcis Fracture management.

Also known as

Heel Bone Fracture
Os Calcis Fracture

Diagnosis Snapshot

Key Facts
  • Definition : Break in the calcaneus (heel bone), often caused by high-impact injuries.
  • Clinical Signs : Heel pain, swelling, bruising, inability to bear weight, deformity.
  • Common Settings : Falls from height, motor vehicle accidents, sports injuries.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC S92.009A Coding
S02.0-S02.9

Fracture of calcaneus

Fractures involving the heel bone.

S00-S99

Injuries to the extremities

Covers injuries like fractures, sprains, and dislocations of limbs.

S02-S02.9

Fractures of lower leg, including ankle

Includes fractures of tibia, fibula, and ankle bones, including calcaneus.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the calcaneal fracture intra-articular (involving the subtalar joint)?

  • Yes

    Displaced fracture?

  • No

    Displaced fracture?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Heel bone break, often from falls.
Stress fracture in heel bone.
Sprain of ligaments around heel.

Documentation Best Practices

Documentation Checklist
  • ICD-10 S92 Fracture calcaneus documentation
  • Laterality (left or right calcaneus)
  • Mechanism of injury (e.g., fall, MVA)
  • Displaced vs. nondisplaced fracture
  • Associated injuries (e.g., spinal, ankle)

Coding and Audit Risks

Common Risks
  • Laterality Coding

    Missing or incorrect laterality (left/right) for calcaneus fracture can lead to claim denials or inaccurate reimbursement.

  • Intra vs Extra-articular

    Distinguishing between intra-articular and extra-articular fractures impacts coding and care planning, posing documentation and coding risks.

  • Displaced vs Non-displaced

    Proper documentation and coding of displacement status is crucial for accurate severity reflection and appropriate reimbursement.

Mitigation Tips

Best Practices
  • Document fracture type, location, displacement for accurate ICD-10 coding (S92).
  • Capture mechanism of injury, e.g., fall from height, for optimal CDI and risk adjustment.
  • Assess neurovascular status and document thoroughly for compliance and quality metrics.
  • Order appropriate imaging studies, including X-ray and CT, to evaluate fracture extent.
  • Consider surgical versus conservative management, documenting rationale for chosen treatment.

Clinical Decision Support

Checklist
  • 1. Verify mechanism of injury (fall, high impact). ICD-10 S92.0
  • 2. Assess pain, swelling, bruising, deformity in heel. Document location.
  • 3. Obtain X-rays (lateral, axial views) to visualize calcaneus. CPT 73630
  • 4. Evaluate for associated injuries (spinal, ankle). Document thoroughly.

Reimbursement and Quality Metrics

Impact Summary
  • Calcaneus Fracture (ICD-10 S92) reimbursement hinges on accurate coding of fracture type, displacement, and laterality for optimal claim processing.
  • Coding quality directly impacts calcaneus fracture reimbursement. Incorrect specificity can lead to denials or reduced payments.
  • Hospital reporting on calcaneus fracture treatment outcomes influences quality metrics tied to patient recovery and complication rates.
  • Accurate documentation of calcaneus fracture diagnosis and treatment details is crucial for appropriate DRG assignment and reimbursement.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Frequently Asked Questions

Common Questions and Answers

Q: What are the key clinical indicators differentiating a simple calcaneus fracture from a more complex intra-articular calcaneus fracture requiring surgical intervention?

A: Differentiating a simple extra-articular calcaneus fracture from a complex intra-articular fracture hinges on careful assessment of several clinical and radiographic factors. While localized tenderness and swelling are common in both, significant hindfoot deformity like varus or valgus malalignment strongly suggests intra-articular involvement. Furthermore, the inability to bear weight, severe pain, and associated injuries like spinal or other lower extremity fractures raise suspicion for a more complex injury. Radiographic evaluation is crucial. Lateral radiographs may reveal Boehler's angle disruption (less than 20-40 degrees) and crucial angles of Gissane. However, CT scans are essential for accurate characterization of intra-articular involvement, fracture displacement, and comminution, crucial for surgical planning. Consider implementing standardized radiographic protocols for suspected calcaneus fractures to ensure accurate diagnosis and inform treatment decisions. Explore how advanced imaging modalities like weight-bearing CT can further enhance surgical planning in complex cases.

Q: How do I determine the most appropriate post-operative rehabilitation protocol following surgical fixation of a comminuted intra-articular calcaneus fracture?

A: Post-operative rehabilitation following surgical fixation of a comminuted intra-articular calcaneus fracture demands a carefully tailored approach based on fracture severity, surgical technique, and patient factors. Early mobilization, while important, must be balanced with protecting the surgical fixation. Typically, non-weight-bearing is maintained for 6-8 weeks followed by gradual weight-bearing progression guided by radiographic healing. Early range of motion exercises for the ankle, subtalar, and midtarsal joints are crucial to prevent stiffness. Physical therapy focuses on restoring strength, proprioception, and gait mechanics. Pain management strategies, including medication and modalities like cryotherapy and compression, are essential components of the rehabilitation process. Learn more about the benefits of incorporating early mobilization protocols while mitigating risks in complex calcaneus fracture cases.

Quick Tips

Practical Coding Tips
  • Code ICD-10 S92.0-S92.9
  • Specify fracture type
  • Document mechanism of injury
  • Query physician for laterality
  • Review X-ray report

Documentation Templates

Patient presents with complaints consistent with calcaneus fracture, also known as a heel bone fracture or os calcis fracture.  Onset of symptoms followed [mechanism of injury, e.g., fall from height, motor vehicle accident].  Patient reports [specific symptoms e.g., severe heel pain, inability to bear weight, swelling, bruising, deformity].  Physical examination reveals [objective findings e.g., point tenderness over the calcaneus, ecchymosis, edema, palpable deformity, crepitus].  Neurovascular status of the foot was assessed and documented as [intact or specify deficits].  Radiographic imaging of the heel, specifically [specify views, e.g., axial, lateral, Harris views], demonstrates [describe fracture characteristics, e.g., intra-articular, extra-articular, comminuted, displaced, avulsion].  Diagnosis of [specific type of calcaneus fracture] confirmed.  Differential diagnoses considered included [list relevant differentials e.g., calcaneal contusion, Achilles tendon rupture, stress fracture].  Treatment plan includes [conservative or surgical options, e.g., RICE protocol, immobilization with a boot or cast, open reduction internal fixation ORIF, closed reduction percutaneous pinning CRPP].  Patient education provided regarding pain management, weight-bearing restrictions, potential complications (e.g., post-traumatic arthritis, complex regional pain syndrome CRPS), follow-up care, and physical therapy.  Patient advised to return for follow-up evaluation in [ timeframe ] to assess healing progress and adjust treatment plan as needed.  ICD-10 code S92.0-S92.9 assigned.
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