Unspecified fracture of lower end of unspecified tibia
ICD-10 S82.309 is a billable code used to indicate a diagnosis of unspecified fracture of lower end of unspecified tibia.
The S82.309 code refers to an unspecified fracture at the lower end of the tibia, which is a common injury often resulting from trauma such as falls, sports injuries, or vehicular accidents. The tibia, or shinbone, is crucial for weight-bearing and mobility, and fractures in this area can significantly impact a patient's ability to walk and perform daily activities. Symptoms typically include 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 involve immobilization with a cast or splint, and in some cases, surgical intervention may be necessary to realign the bone fragments. Rehabilitation is often required to restore function and strength. The unspecified nature of this code indicates that the specific type of fracture (e.g., transverse, oblique, or comminuted) is not documented, which can complicate treatment planning and coding accuracy.
Detailed operative reports, imaging studies, and follow-up notes are essential.
Fractures resulting from sports injuries, falls, or accidents requiring surgical intervention.
Ensure that all associated injuries (e.g., ligament tears) are documented to support comprehensive coding.
Comprehensive assessments of functional limitations and rehabilitation progress.
Patients undergoing rehabilitation post-fracture for mobility restoration.
Documenting the impact of the fracture on daily activities and rehabilitation goals is crucial.
Used when surgical intervention is required for fracture stabilization.
Operative report detailing the procedure, indications, and post-operative care.
Orthopedic surgeons must document the fracture type and any associated injuries.
Document the mechanism of injury, specific symptoms, imaging results, and any associated injuries. Ensure that the clinical notes clearly indicate the fracture's impact on the patient's function.
