Find information on right calcaneal fracture diagnosis, including ICD-10 codes S92.0 and S92.1, clinical documentation requirements, heel bone fracture treatment, and post-operative care. Learn about calcaneus fracture diagnosis coding, radiology, and medical billing guidelines for accurate healthcare claim submission. Explore resources for physicians, coders, and healthcare professionals managing calcaneal fractures.
Also known as
Fracture of calcaneus
Covers fractures of the calcaneus (heel bone).
Injuries to the ankle and foot
Includes various injuries like sprains, strains, and fractures.
Injuries, poisonings, etc.
Encompasses a broad range of external causes of injury.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the fracture displaced?
Yes
Intra-articular?
No
Intra-articular?
When to use each related code
Description |
---|
Right Calcaneal Fracture |
Left Calcaneal Fracture |
Calcaneal Stress Fracture |
Incorrectly coding the left vs. right calcaneus, leading to claim denials or inaccurate data reporting. Focus on documentation clarity.
Lack of documentation specifying the fracture type (e.g., displaced, intra-articular). Impacts reimbursement and quality metrics. CDI crucial.
Failure to capture additional injuries (e.g., soft tissue damage, other fractures) present with the calcaneal fracture. Affects severity and reimbursement.
Patient presents with complaints of right heel pain following a fall or injury. Onset of pain was (acute or insidious) and is described as (sharp, dull, aching, throbbing). Pain is exacerbated by weight-bearing and ambulation. Patient reports (difficulty walking, inability to bear weight, limping). Associated symptoms may include swelling, bruising, and tenderness to palpation over the right calcaneus. Mechanism of injury reported as (fall from height, twisting injury, direct impact). Physical examination reveals (edema, ecchymosis, point tenderness) over the right heel. Range of motion of the right ankle and foot is (limited, normal) with pain noted on (inversion, eversion, plantarflexion, dorsiflexion). Neurovascular assessment of the right foot is intact. Radiographic imaging of the right foot and ankle (X-ray, CT scan) demonstrates a fracture of the calcaneus, classified as (intra-articular, extra-articular) with (comminution, displacement) noted. Differential diagnosis includes calcaneal contusion, Achilles tendon rupture, and ankle sprain. Assessment: Closed fracture of the right calcaneus. Plan: Conservative management with (rest, ice, compression, elevation), immobilization with a (boot, splint, cast), pain management with (NSAIDs, analgesics), and referral to orthopedics for definitive treatment. Follow-up scheduled in (number) weeks for reevaluation and discussion of further management options, including surgical intervention if indicated. Patient education provided on fracture care, weight-bearing restrictions, and potential complications such as post-traumatic arthritis. ICD-10 code S92.0xxA assigned.