Find information on Right Distal Tibia Fracture diagnosis, including clinical documentation tips, ICD-10-CM codes S82.401A, S82.401D, S82.401G, S82.401S for initial, subsequent, and sequela encounters, and medical coding guidelines. Learn about distal tibia fracture treatment, recovery, and documentation best practices for accurate healthcare billing and coding. Explore resources for physicians, coders, and other healthcare professionals regarding Right Distal Tibia Fractures.
Also known as
Fracture of lower end of tibia
Fractures involving the distal end of the tibia bone.
Fracture of lower leg
Fractures involving the tibia, fibula, or both.
Fractures of lower limb
Encompasses all fractures from the hip to the toes.
Injuries, poisonings, external causes
Includes various injuries, including fractures, and their external causes.
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 nondisplaced?
When to use each related code
| Description |
|---|
| Right distal tibia fracture |
| Right distal fibula fracture |
| Right ankle fracture NOS |
Coding error due to incorrect laterality (right vs. left) documented in clinical notes conflicting with imaging reports, impacting reimbursement.
Unspecified fracture type (e.g., displaced, open) leads to inaccurate code assignment, impacting DRG and quality reporting.
Failure to code associated injuries (e.g., fibula fracture, ligament tear) with the tibia fracture, impacting severity and reimbursement.
Patient presents with complaints of right ankle pain and swelling following a twisting injury while playing basketball. On examination, there is tenderness to palpation over the distal right tibia, with notable edema and ecchymosis. Pain is exacerbated with weight-bearing and range of motion. Distal neurovascular status is intact. Radiographic imaging of the right ankle reveals a closed, displaced fracture of the distal tibia, specifically involving the metaphysis and extending into the articular surface. Diagnosis of right distal tibia fracture is confirmed. Initial treatment includes immobilization with a splint, elevation, ice, and pain management with ibuprofen. Orthopedic consultation is recommended for definitive management, which may include closed reduction, open reduction internal fixation (ORIF), or casting, depending on fracture displacement and stability. Differential diagnoses considered included ankle sprain, fibular fracture, and distal tibiofibular syndesmosis injury. Patient education provided regarding fracture care, potential complications such as compartment syndrome and delayed union, and follow-up instructions. ICD-10 code S82.401A assigned for closed fracture of the distal tibia, right side, initial encounter for closed fracture. Appropriate CPT codes will be determined based on the definitive treatment provided by orthopedics.