ICD-10 Coding for Trimalleolar Fracture(S82.85XA)
Complete ICD-10-CM coding and documentation guide for Trimalleolar Fracture. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Trimalleolar Fracture
S82.85-S82.89Primary Range
Fracture of the lower leg, including ankle
This range includes specific codes for trimalleolar fractures, detailing laterality and displacement status.
Key Information: ICD-10 code for trimalleolar fracture
Essential facts and insights about Trimalleolar Fracture
Primary ICD-10-CM Code for trimalleolar fracture
Decision Criteria
clinical Criteria
- Presence of fracture in lateral, medial, and posterior malleoli with displacement
Applicable To
- Displaced fracture of lateral, medial, and posterior malleoli
Excludes
- Bimalleolar fracture
- Pilon fracture
Clinical Validation Requirements
- Imaging confirmation of all three malleoli fractures
- Displacement >2mm on X-ray/CT
Code-Specific Risks
- Confusion with bimalleolar fractures
- Incorrect laterality documentation
Coding Notes
- Ensure documentation specifies all three malleoli and displacement status.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Open treatment of trimalleolar fracture without posterior lip fixation
27822Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Bimalleolar fracture
S82.84X-Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Trimalleolar Fracture to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S82.85XA.
Impact
Clinical: Impacts treatment decisions, Regulatory: Non-compliance with documentation standards, Financial: Potential for denied claims
Mitigation Strategy
Always document left or right in clinical notes, Use templates that prompt for laterality
Impact
Reimbursement: Incorrect coding may lead to lower reimbursement., Compliance: Non-compliance with coding standards., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Verify imaging to confirm involvement of all three malleoli.
Impact
Risk of audits due to incorrect fracture type coding.
Mitigation Strategy
Regular training on fracture coding and documentation.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Trimalleolar Fracture, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Trimalleolar Fracture
Use these documentation templates to ensure complete and accurate documentation for Trimalleolar Fracture. These templates include all required elements for proper coding and billing.
Initial encounter for displaced trimalleolar fracture
Specialty: OrthopedicsRequired Elements
- Patient history
- Mechanism of injury
- Imaging results
- Physical examination findings
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Trimalleolar Fracture? Ask your questions below.