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ICD-10 Guide
ICD-10 CodesS82.401

S82.401

Billable

Unspecified fracture of shaft of right fibula

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

Code Description

ICD-10 S82.401 is a billable code used to indicate a diagnosis of unspecified fracture of shaft of right fibula.

Key Diagnostic Point:

An unspecified fracture of the shaft of the right fibula refers to a break in the fibula bone, which is located on the lateral side of the leg and runs parallel to the tibia. This type of fracture can occur due to various mechanisms, including trauma from falls, sports injuries, or accidents. The fibula plays a crucial role in stabilizing the ankle and supporting the muscles of the lower leg. Fractures of the fibula can be classified as either closed or open, depending on whether the skin is broken. Symptoms typically include pain, swelling, bruising, and difficulty bearing weight on the affected leg. Diagnosis is usually confirmed through imaging studies such as X-rays. Treatment may involve conservative management with rest, ice, compression, and elevation (RICE), or surgical intervention in cases of displacement or instability. Rehabilitation is essential for restoring function and strength to the leg post-injury. Accurate coding of this condition is vital for appropriate treatment and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in fracture types and locations
  • Need for precise documentation of injury mechanism
  • Differentiation from other lower leg injuries
  • Potential for associated injuries (e.g., ligament tears)

Audit Risk Factors

  • Inadequate documentation of fracture specifics
  • Failure to document associated injuries
  • Inconsistent coding with treatment provided
  • Lack of follow-up documentation

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed notes on the mechanism of injury, imaging results, and treatment plan.

Common Clinical Scenarios

Fractures resulting from sports injuries, falls, or vehicular accidents.

Billing Considerations

Ensure that all associated injuries (e.g., ligament tears) are documented and coded appropriately.

Physical Therapy

Documentation Requirements

Progress notes detailing rehabilitation exercises and patient response.

Common Clinical Scenarios

Post-fracture rehabilitation and recovery protocols.

Billing Considerations

Document functional limitations and progress towards rehabilitation goals.

Coding Guidelines

Inclusion Criteria

Use S82.401 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the code accurately reflects the clinical documentation
  • Include details about the fracture type, location, and any associated injuries

Exclusion Criteria

Do NOT use S82.401 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

27814CPT Code

Open treatment of fibula fracture

Clinical Scenario

Used when surgical intervention is required for an unstable fibula fracture.

Documentation Requirements

Operative report detailing the procedure and findings.

Specialty Considerations

Orthopedic surgeons must document the specifics of the fracture and the surgical approach.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 allows for more detailed coding of fractures, improving specificity and accuracy in billing and treatment planning.

ICD-9 vs ICD-10

The transition to ICD-10 allows for more detailed coding of fractures, improving specificity and accuracy in billing and treatment planning.

Reimbursement & Billing Impact

billing and 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 S82.401 and S82.402?

S82.401 refers to an unspecified fracture of the shaft of the right fibula, while S82.402 specifies a fracture of the shaft of the left fibula. Accurate coding requires attention to the side of the injury.