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ICD-10 Guide
ICD-10 CodesS82.1

S82.1

Billable

Fracture of upper end of tibia

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

Code Description

ICD-10 S82.1 is a billable code used to indicate a diagnosis of fracture of upper end of tibia.

Key Diagnostic Point:

A fracture of the upper end of the tibia, also known as a proximal tibial fracture, typically occurs due to high-energy trauma such as falls, motor vehicle accidents, or sports injuries. This type of fracture can involve the knee joint, leading to complications such as instability, malalignment, and potential damage to surrounding ligaments and cartilage. The upper end of the tibia is crucial for weight-bearing and mobility, making accurate diagnosis and treatment essential. Symptoms often include severe pain, swelling, bruising, and difficulty bearing weight on the affected leg. Diagnosis is confirmed through imaging studies, primarily X-rays, which can reveal the fracture pattern and any associated injuries. Treatment may involve conservative management with immobilization or surgical intervention, such as internal fixation or orthopedic reconstructive procedures, depending on the fracture's complexity and the patient's overall health. Rehabilitation is critical for restoring function and strength to the knee and leg following recovery.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in fracture patterns (e.g., comminuted, displaced)
  • Potential for associated ligament injuries (e.g., ACL, MCL tears)
  • Need for surgical intervention and reconstruction
  • Variations in treatment protocols across specialties

Audit Risk Factors

  • Inadequate documentation of fracture type and location
  • Failure to document associated injuries (e.g., ligament tears)
  • Misclassification of fracture severity
  • Lack of clarity in surgical reports

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed surgical notes, imaging reports, and post-operative care plans.

Common Clinical Scenarios

Surgical repair of proximal tibial fractures, management of complications such as infections or non-unions.

Billing Considerations

Ensure accurate coding of any associated procedures, such as ligament reconstruction.

Physical Therapy

Documentation Requirements

Progress notes detailing rehabilitation protocols and patient responses.

Common Clinical Scenarios

Rehabilitation following surgical repair of tibial fractures, management of knee instability.

Billing Considerations

Document functional assessments and progress towards rehabilitation goals.

Coding Guidelines

Inclusion Criteria

Use S82.1 When
  • Follow official ICD
  • CM guidelines for coding fractures, including specificity regarding the type and location of the fracture
  • Ensure to document any associated conditions or complications

Exclusion Criteria

Do NOT use S82.1 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

27506CPT Code

Open treatment of tibial plateau fracture

Clinical Scenario

Used when surgical intervention is required for a proximal tibial fracture.

Documentation Requirements

Surgical reports detailing the procedure, fixation method, and post-operative care.

Specialty Considerations

Orthopedic surgeons must document the fracture type and any associated injuries.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding fractures, improving the accuracy of patient records and facilitating better treatment planning.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding fractures, improving the accuracy of patient records and facilitating better treatment planning.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for greater specificity in coding fractures, improving the accuracy of patient records and facilitating better treatment planning.

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 S82.1 and S82.10?

S82.1 refers specifically to a fracture of the upper end of the tibia, while S82.10 is used when the fracture type is unspecified.