Find information on proximal tibia fracture diagnosis, including clinical documentation, medical coding, and healthcare resources. Learn about ICD-10 codes for proximal tibia fractures, treatment options, and proper documentation for accurate billing and reimbursement. Explore resources for physicians, coders, and other healthcare professionals related to proximal tibia fracture care, diagnosis codes, and best practices for clinical documentation. Research proximal tibia fracture types, anatomical location, and associated injuries for comprehensive understanding and accurate medical coding.
Also known as
Fracture of upper end of tibia
This range encompasses fractures specifically at the proximal end of the tibia.
Fracture of tibia and fibula
Includes all fractures of the tibia, often involving the fibula as well.
Fractures of lower extremity
Broad category for fractures occurring anywhere in the lower limb.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the fracture closed?
Yes
Lateral condyle?
No
Lateral condyle?
When to use each related code
| Description |
|---|
| Proximal Tibia Fracture |
| Tibial Plateau Fracture |
| Tibial Shaft Fracture |
Missing or incorrect laterality (right, left, unspecified) for proximal tibia fracture impacts reimbursement and data accuracy. ICD-10 coding requires specificity.
Coding to the correct level of detail for proximal tibia fractures (e.g., plateau, shaft, tuberosity) is crucial for accurate severity reflection and appropriate DRG assignment.
Failing to code associated injuries (e.g., fibular fracture, ligament tears) with proximal tibia fractures can lead to underreporting severity and missed CC/MCC capture.
Patient presents with complaints of pain, swelling, and limited range of motion in the proximal tibia region following a [mechanism of injury - e.g., fall, sports injury, motor vehicle accident]. Physical examination reveals tenderness to palpation over the proximal tibia, with possible ecchymosis and deformity. Neurovascular status of the affected limb was assessed and documented as [intact or specify deficit]. Radiographic imaging of the proximal tibia, including [specify views - e.g., AP, lateral, oblique], confirms a fracture involving the [specify location - e.g., tibial plateau, proximal tibial metaphysis, tibial tuberosity] with [describe fracture characteristics - e.g., displacement, comminution, articular involvement]. Diagnosis of proximal tibia fracture is made. Differential diagnoses considered include tibial contusion, meniscus tear, ligamentous injury. Treatment plan includes [conservative management or surgical intervention]. Conservative management may involve immobilization with a cast, brace, or splint, pain management with analgesics, and physical therapy for rehabilitation. Surgical options may include open reduction internal fixation (ORIF), external fixation, or intramedullary nailing depending on the fracture pattern and severity. Patient education provided regarding proximal tibia fracture recovery, weight-bearing restrictions, and potential complications. Follow-up scheduled in [timeframe] to assess healing progress and adjust treatment plan as needed. ICD-10 code [specify code - e.g., S82.109A] assigned. CPT codes for procedures will be documented upon completion.