Unspecified fracture of shaft of right tibia
ICD-10 S82.201 is a billable code used to indicate a diagnosis of unspecified fracture of shaft of right tibia.
An unspecified fracture of the shaft of the right tibia refers to a break in the long bone located in the lower leg, specifically the tibia, which is crucial for weight-bearing and mobility. This type of fracture can occur due to various mechanisms, including trauma from falls, sports injuries, or accidents. The tibia is often subjected to significant stress, and fractures can range from simple, non-displaced fractures to complex, comminuted fractures. Symptoms typically include pain, swelling, 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 more severe cases, surgical intervention may be necessary to realign the bone fragments. Rehabilitation is essential for restoring function and strength to the leg post-injury. The unspecified nature of this code indicates that further details about the fracture type and severity are not provided, which can complicate treatment planning and coding accuracy.
Detailed operative notes, imaging results, and follow-up care plans are essential for accurate coding.
Fractures resulting from sports injuries, falls, or vehicular accidents.
Orthopedic surgeons must provide clear documentation of fracture type, treatment rationale, and any surgical interventions performed.
Comprehensive assessments of functional status and rehabilitation progress are necessary.
Patients undergoing rehabilitation post-fracture for strength and mobility restoration.
Documentation should reflect the patient's progress and any complications that may arise during rehabilitation.
Used when surgical intervention is performed for a tibial shaft fracture.
Operative reports detailing the procedure, indications, and post-operative care.
Orthopedic surgeons must ensure that the procedure aligns with the diagnosis and that all documentation supports the surgical intervention.
S82.201 is used for unspecified fractures of the shaft of the right tibia, while S82.202 is for displaced fractures of the same area. The choice of code depends on the specifics of the fracture as documented in the medical record.
