Unspecified fracture of shaft of unspecified tibia
ICD-10 S82.209 is a billable code used to indicate a diagnosis of unspecified fracture of shaft of unspecified tibia.
An unspecified fracture of the shaft of the tibia refers to a break in the long bone of 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 fractured in conjunction with injuries to surrounding structures, such as the fibula, ligaments, and muscles, particularly around the knee joint. The clinical presentation may include pain, swelling, and inability to bear weight on the affected leg. Diagnosis typically involves physical examination and imaging studies, such as X-rays, to confirm the fracture and assess its severity. Treatment options may vary based on the fracture's characteristics and may include conservative management with immobilization or surgical intervention for more complex cases. Rehabilitation is often necessary to restore function and strength to the affected limb. Accurate coding is essential for appropriate treatment planning and reimbursement.
Detailed notes on fracture type, location, and treatment plan are essential.
Fractures resulting from sports injuries, falls, or vehicular accidents.
Ensure that all imaging results and treatment decisions are documented to support coding.
Documentation of functional limitations and rehabilitation goals is critical.
Post-operative rehabilitation following surgical fixation of tibial fractures.
Include details on the patient's progress and response to therapy.
Used when surgical intervention is performed for a tibial fracture.
Operative report detailing the procedure and findings.
Orthopedic surgeons must document the specifics of the fracture and treatment.
Use S82.209 when the documentation does not specify the type of tibial fracture, and no other more specific codes apply.
