ICD 10 CM S82.101D | Description & Clinical Information

ICD 10 S82.101D describes a type of fracture that occurs in the upper end of the right tibia, which is the larger and stronger of the two bones in the right lower leg, typically just below the knee, resulting from various causes such as falls from high elevations, traffic accidents, or sports injuries, and is more common in the elderly due to thinning of the bones and cancer, and is characterized by a break or discontinuity with or without displacement of the fracture fragments, and is not specified by the provider as a type of fracture at a subsequent encounter for a normally healing, closed fracture that is not exposed through a tear or laceration in the skin.

Official Description Of S82.101D

The ICD 10 CM book defines ICD 10 code S82.101D as:

Clinical Information

The diagnosis describes by the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code S82.101D is an unspecified fracture of the upper end of the right tibia. This type of fracture is often referred to as a proximal tibia fracture and can result in a range of symptoms, including severe pain on moving the leg or with weightbearing, swelling, tenderness, bruising over the affected site, difficulty moving the leg, restricted range of motion, and deformity, especially of the knee. Furthermore, patients with this type of fracture may experience numbness and tingling if nerve and blood vessel damage accompany the injury.

Healthcare providers diagnose this condition based on the patient’s clinical presentation and medical history, with particular attention to nerves, blood vessels, and reflexes. As part of the diagnosis, laboratory studies are necessary to assess or follow up on blood loss, blood clotting, muscle injury, and other factors contributing to or caused by the injury. Additionally, imaging techniques such as anteroposterior (AP) and lateral view X-rays, computed tomography (CT), magnetic resonance imaging (MRI), and bone scans can be used to assess the severity of the injury.

Stable and closed fractures can be treated using skeletal traction or a splint, brace, or cast to restrict limb movement as they rarely require surgery. However, unstable fractures require open or closed reduction and fixation, and open fractures require surgery to close the wound. In addition to surgery or immobilization, pain management is also a crucial aspect of treatment. Depending on the severity of the pain, the provider may prescribe narcotic analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs).

As healing progresses, rehabilitation must begin, including exercises to improve flexibility, strength, and range of motion. Rehabilitation can help patients regain function and return to their usual activity level. Timeframes for recovery vary depending on the severity of the injury, the type of treatment, and the patient’s overall health.

In conclusion, an unspecified fracture of the upper end of the right tibia, or a proximal tibia fracture, can cause severe and potentially disabling symptoms. With proper diagnosis and treatment, patients can recover and return to normal activities. The healthcare provider plays a critical role in determining the most appropriate course of treatment based on the patient’s needs, using appropriate medical coding to accurately document the diagnosis and treatment rendered. Correct coding and proper documentation ensure that the patient receives accurate and timely payment for services rendered, as well as facilitating research and population health management.