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ICD-10 Guide
ICD-10 CodesS82.301

S82.301

Billable

Unspecified fracture of lower end of right tibia

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/26/2025

Code Description

ICD-10 S82.301 is a billable code used to indicate a diagnosis of unspecified fracture of lower end of right tibia.

Key Diagnostic Point:

An unspecified fracture of the lower end of the right tibia refers to a break in the tibia bone, which is located in the lower leg, just above the ankle. This type of fracture can occur due to various mechanisms, including trauma from falls, sports injuries, or accidents. The lower end of the tibia is critical for weight-bearing and mobility, and fractures in this area can lead to significant functional impairment. Symptoms typically include localized pain, swelling, bruising, and difficulty bearing weight on the affected leg. Diagnosis is usually confirmed through imaging studies such as X-rays or CT scans. Treatment may vary based on the severity of the fracture and can range from conservative management with immobilization to surgical intervention for more complex fractures. Rehabilitation is often necessary to restore function and strength to the leg following healing. Accurate coding is essential for proper treatment planning and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in fracture types and locations
  • Need for precise documentation of injury mechanism
  • Potential for associated soft tissue injuries
  • Differentiation from other lower leg fractures

Audit Risk Factors

  • Use of unspecified codes without adequate documentation
  • Inconsistent documentation of injury mechanism
  • Failure to document associated injuries or conditions
  • Inadequate follow-up documentation post-treatment

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative reports, imaging studies, and follow-up notes are essential for accurate coding.

Common Clinical Scenarios

Fractures resulting from sports injuries, falls, or vehicular accidents.

Billing Considerations

Documentation must clearly indicate the fracture type and any associated injuries to support the use of this code.

Physical Medicine and Rehabilitation

Documentation Requirements

Comprehensive assessments of functional status and rehabilitation progress.

Common Clinical Scenarios

Patients undergoing rehabilitation post-fracture for strength and mobility restoration.

Billing Considerations

Documentation should reflect the patient's functional limitations and goals for therapy.

Coding Guidelines

Inclusion Criteria

Use S82.301 When
  • Follow official ICD
  • 10 coding guidelines, ensuring that the code is used only when the fracture is confirmed and documented

Exclusion Criteria

Do NOT use S82.301 When
  • Exclude codes for specific fractures or conditions that may better describe the patient's injury

Related ICD-10 Codes

Related CPT Codes

27814CPT Code

Open treatment of tibial fracture

Clinical Scenario

Used when surgical intervention is required for fracture repair.

Documentation Requirements

Operative report detailing the procedure and any complications.

Specialty Considerations

Orthopedic surgeons must document the specifics of the fracture and treatment approach.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specificity in coding fractures, which can improve patient care and reimbursement accuracy. However, it also requires coders to be more diligent in documentation to avoid unspecified codes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specificity in coding fractures, which can improve patient care and reimbursement accuracy. However, it also requires coders to be more diligent in documentation to avoid unspecified codes.

Reimbursement & Billing Impact

reimbursement accuracy. However, it also requires coders to be more diligent in documentation to avoid unspecified codes.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the difference between S82.301 and S82.302?

S82.301 is used for unspecified fractures, while S82.302 is for displaced fractures of the lower end of the right tibia. Accurate documentation is crucial to determine the correct code.