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ICD-10 Guide
ICD-10 CodesS82.101

S82.101

Billable

Unspecified fracture of upper end of right tibia

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

Code Description

ICD-10 S82.101 is a billable code used to indicate a diagnosis of unspecified fracture of upper end of right tibia.

Key Diagnostic Point:

An unspecified fracture of the upper end of the right tibia refers to a break in the bone located at the proximal end of the tibia, which is crucial for weight-bearing and mobility. This type of fracture often occurs due to high-impact trauma, such as falls or motor vehicle accidents, and can be associated with knee injuries, including ligament tears. The upper end of the tibia articulates with the femur and fibula, making it integral to knee stability and function. Symptoms typically include localized pain, swelling, and difficulty bearing weight on the affected leg. Diagnosis is confirmed through imaging studies, such as X-rays or MRI, which help assess the fracture's nature and any associated soft tissue injuries. Treatment may involve conservative management with immobilization or surgical intervention, depending on the fracture's complexity and the presence of additional injuries. Rehabilitation is essential for restoring function and strength to the knee joint following recovery.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in fracture types and associated injuries
  • Need for precise documentation of fracture details
  • Potential for co-existing ligament injuries
  • Variations in treatment approaches based on fracture severity

Audit Risk Factors

  • Inadequate documentation of fracture specifics
  • Failure to document associated injuries (e.g., ligament tears)
  • Misuse of unspecified codes when specific codes are available
  • Inconsistent treatment documentation

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed descriptions of the fracture type, location, and any associated injuries must be documented, along with treatment plans.

Common Clinical Scenarios

Fractures resulting from sports injuries, falls, or accidents requiring surgical intervention.

Billing Considerations

Ensure accurate coding of any surgical procedures performed, including fixation methods and rehabilitation protocols.

Physical Therapy

Documentation Requirements

Documentation of functional limitations, treatment goals, and progress notes related to rehabilitation.

Common Clinical Scenarios

Patients recovering from tibial fractures undergoing physical therapy to regain strength and mobility.

Billing Considerations

Document the specific exercises and modalities used to ensure proper linkage to the diagnosis.

Coding Guidelines

Inclusion Criteria

Use S82.101 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the fracture's specifics
  • Include any associated injuries or conditions that may affect treatment and recovery

Exclusion Criteria

Do NOT use S82.101 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

27506CPT Code

Open treatment of tibial fracture

Clinical Scenario

Used when surgical intervention is required for fracture stabilization.

Documentation Requirements

Operative reports detailing the procedure and any implants used.

Specialty Considerations

Orthopedic surgeons must ensure accurate coding of the procedure in relation to the diagnosis.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more detailed coding of fractures, improving specificity and enhancing the ability to track treatment outcomes and complications.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more detailed coding of fractures, improving specificity and enhancing the ability to track treatment outcomes and complications.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more detailed coding of fractures, improving specificity and enhancing the ability to track treatment outcomes and complications.

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 S82.101 and S82.102?

S82.101 refers to an unspecified fracture of the upper end of the right tibia, while S82.102 refers to the same type of fracture on the left side. Accurate coding requires specifying the side of the injury.