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ICD-10 Guide
ICD-10 CodesS82.116

S82.116

Billable

Nondisplaced fracture of unspecified tibial spine

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

Code Description

ICD-10 S82.116 is a billable code used to indicate a diagnosis of nondisplaced fracture of unspecified tibial spine.

Key Diagnostic Point:

A nondisplaced fracture of the tibial spine refers to a break in the bone that does not result in the bone fragments being misaligned. The tibial spine is a critical area located at the proximal end of the tibia, where the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) attach. This type of fracture is often associated with knee injuries, particularly in athletes or individuals involved in high-impact sports. Symptoms typically include localized pain, swelling, and limited range of motion in the knee. Diagnosis is usually confirmed through imaging studies such as X-rays or MRI, which can help visualize the fracture and assess any associated ligamentous injuries. Treatment may involve conservative management, including rest, ice, compression, and elevation (RICE), along with physical therapy to restore function. In some cases, surgical intervention may be necessary if there are concurrent ligament tears or if the fracture does not heal properly. Understanding the implications of this fracture is crucial for effective management and rehabilitation, as it can significantly impact knee stability and function.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation of fracture types and locations
  • Need for precise imaging interpretation
  • Potential for associated ligament injuries complicating coding
  • Differentiation from other knee injuries and fractures

Audit Risk Factors

  • Inadequate documentation of fracture specifics
  • Failure to document associated injuries or treatments
  • Misclassification of fracture type (displaced vs. nondisplaced)
  • Lack of follow-up documentation on healing progress

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed imaging reports, surgical notes, and follow-up assessments are essential for accurate coding.

Common Clinical Scenarios

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

Billing Considerations

Documentation must clearly differentiate between nondisplaced and displaced fractures, as well as any associated ligament injuries.

Physical Therapy

Documentation Requirements

Progress notes detailing rehabilitation exercises, patient response, and functional outcomes.

Common Clinical Scenarios

Rehabilitation following a tibial spine fracture, focusing on restoring knee function and strength.

Billing Considerations

Therapists should document the specific limitations caused by the fracture to support the need for therapy.

Coding Guidelines

Inclusion Criteria

Use S82.116 When
  • According to ICD
  • 10 guidelines, S82
  • 116 should be used when a nondisplaced fracture of the tibial spine is confirmed without any additional details regarding the specific location
  • Coders must ensure that the documentation supports the diagnosis and that any associated injuries are also coded appropriately

Exclusion Criteria

Do NOT use S82.116 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

27405CPT Code

Arthroscopy, knee, surgical; with ACL reconstruction

Clinical Scenario

Used when surgical intervention is required for associated ligament injuries.

Documentation Requirements

Surgical notes must detail the procedure performed and the findings.

Specialty Considerations

Orthopedic surgeons must document the rationale for surgery and any associated findings.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of fractures, including nondisplaced fractures of the tibial spine, which enhances the accuracy of patient records and treatment plans.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of fractures, including nondisplaced fractures of the tibial spine, which enhances the accuracy of patient records and treatment plans.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of fractures, including nondisplaced fractures of the tibial spine, which enhances the accuracy of patient records and treatment plans.

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 a nondisplaced and displaced fracture?

A nondisplaced fracture means the bone cracks but maintains its proper alignment, while a displaced fracture involves the bone fragments being misaligned.