ICD-10 Guide

Proximal Tibia Fracture

ICD-10 Coding for Proximal Tibia Fracture(S82.121A, S82.141A)

PRIMARY SPECIALTYOrthopedics

COMPLEXITYHigh

LAST UPDATED09/15/2025

Sam Tuffun, PT, DPT

Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Proximal Tibia Fracture?

Essential facts and insights about Proximal Tibia Fracture

Key Clinical Considerations:

Localized pain and swelling around the knee
Inability to bear weight on the affected leg
Deformity or abnormal positioning of the knee

Clinical Information

Clinical Criteria & Documentation Requirements

Patient history including mechanism of injury
Imaging reports (X-rays, CT scans) confirming fracture
Detailed physical examination notes including range of motion and stability

Coding Guidelines

Usage Guidelines & Examples

Ensure to differentiate between closed and open fractures.
Common errors include incorrect laterality and encounter type.

Code Exclusions

Important Exclusions

Fractures of the distal tibia or fibula
Pathological fractures due to underlying conditions

Specialty Focus

Primary Specialty

Orthopedics

Specialty Applications

Adults and children with traumatic injuries
Emergency departments and orthopedic clinics

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

Comprehensive clinical documentation
Accurate code selection based on clinical criteria
Proper exclusion considerations
Specialty-specific coding guidelines

Documentation

Documentation Templates

Billing Information

Billing Considerations

Ensure proper documentation for billing
Verify code specificity requirements
Check for any additional codes needed
Review payer-specific guidelines

Common Issues

Insufficient clinical documentation
Incorrect code selection
Missing supporting diagnoses
Timing and frequency documentation

Frequently Asked Questions

Documentation requirements?

Include detailed history, physical exam findings, and imaging results.

Billing considerations?

Ensure correct coding for initial encounter and specify laterality.

Proximal Tibia Fracture

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

Documentation requirements?

Billing considerations?

Proximal Tibia Fracture

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

Documentation requirements?

Billing considerations?