2025 ICD-10-CM code S82.234J
(Active) Effective Date: N/A Injury, poisoning and certain other consequences of external causes - Injuries to the knee and lower leg 19 Feed
Nondisplaced oblique fracture of shaft of right tibia, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing.
Medical necessity is established by the presence of a documented open fracture of the right tibia with delayed healing. Continued care and treatment are required to address the delayed healing and prevent complications. Supporting documentation, such as x-rays showing lack of callus formation or signs of infection, is crucial.
In simple words: The patient has a broken right shinbone that went through the skin. It's not healing as quickly as it should.
This code describes a non-displaced, angled fracture of the shaft (the long, central part) of the right tibia (shinbone), one of the two bones in the lower leg. It is used for a subsequent encounter, meaning the patient is being seen after the initial treatment for the fracture. The fracture is specified as an open fracture, Gustilo types IIIA, IIIB, or IIIC, indicating a break in the skin and varying degrees of soft tissue damage. Furthermore, the healing process is delayed, signifying it's not progressing at the expected rate.
Example 1: A patient initially presented with an open fracture of the right tibial shaft, classified as Gustilo type IIIA. After initial treatment, they return for a follow-up appointment and the physician determines the healing is delayed. Code S82.234J is used., A patient sustained a Gustilo type IIIB open fracture of their right tibia in a motorcycle accident. They underwent surgical repair of the bone and soft tissues. Weeks later, during a follow-up visit, the fracture shows signs of delayed healing. The provider documents S82.234J., A patient with an open fracture of the right tibia, Gustilo type IIIC, had initial debridement and external fixation. Upon re-evaluation, there are signs of infection and delayed bone union. The documentation supports the use of S82.234J.
Documentation should include details of the initial injury, type of open fracture (Gustilo classification), evidence of delayed healing (e.g., x-rays, clinical findings), and all treatment provided.
- Specialties:Orthopedic Surgery, Trauma Surgery
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital, Office, Telehealth Provided in Patient’s Home, Telehealth Provided Other than in Patient’s Home