Find comprehensive information on Left Tibia Fracture diagnosis, including clinical documentation, medical coding (ICD-10, CPT), treatment protocols, and healthcare resources. Learn about left tibial shaft fractures, proximal tibia fractures, distal tibia fractures, and associated fibula fractures. Explore resources for accurate fracture documentation, coding guidelines, and best practices for patient care related to left tibia fractures.
Also known as
Fracture of lower leg
Fractures involving the tibia and/or fibula.
Fracture of shaft of tibia
Fractures specifically located in the tibial shaft.
Fracture of shaft of tibia, unspecified
Unspecified fractures of the tibial shaft, not further classified.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the fracture open or closed?
Open
Type of open fracture?
Closed
Displaced or non-displaced?
When to use each related code
| Description |
|---|
| Left Tibia Fracture |
| Left Tibial Plateau Fracture |
| Left Tibia Shaft Fracture |
Coding with unspecified fracture codes (e.g., S82.90) when more specific documentation is available, leading to lower reimbursement and data quality issues.
Incorrectly coding laterality (left vs. right) or failing to document it, impacting claims accuracy and potentially causing patient safety concerns.
Missing documentation or coding for associated injuries (e.g., fibula fracture, soft tissue damage) which are clinically relevant and affect reimbursement.
Patient presents with complaints of left leg pain and swelling following a [mechanism of injury - e.g., fall, motor vehicle accident, sports injury]. On physical examination, there is tenderness, edema, and ecchymosis over the left tibial shaft. Deformity may be present. Neurovascular status of the left lower extremity was assessed and documented. Radiographic imaging of the left tibia and fibula reveals a fracture of the [specify location: proximal, midshaft, distal] tibia. The fracture is characterized as [describe fracture type: transverse, oblique, spiral, comminuted, segmental] and is [specify displacement: nondisplaced, displaced, angulated]. The fibula is [intact or fractured]. Differential diagnosis includes stress fracture, contusion, and soft tissue injury. Assessment: Closed fracture of the left tibia. Plan: Patient will be treated with [conservative management: immobilization with a cast, splint, or brace] or [surgical management: open reduction internal fixation, external fixation] depending on fracture characteristics and stability. Pain management with [specify medication] prescribed. Patient education provided regarding weight-bearing status, follow-up care, and potential complications such as compartment syndrome, deep vein thrombosis, and infection. Referral to orthopedics scheduled. Return to clinic in [ timeframe ] for follow-up evaluation and repeat radiographs. ICD-10 code: [appropriate code based on specific fracture characteristics - e.g., S82.101A for unspecified fracture of the shaft of left tibia, initial encounter for closed fracture].