2025 ICD-10-CM code S82.401A
Unspecified fracture of shaft of right fibula, initial encounter for closed fracture.
Medical necessity is established by the presence of a fracture confirmed by imaging.The documentation should support the need for the specific treatment provided, whether it's conservative management or surgical intervention.A secondary code should describe what caused the injury according to ICD-10 guidelines.
The provider diagnoses the fracture based on patient history, physical examination (including neurovascular and musculoskeletal exams), and imaging studies (X-rays, CT, MRI, or bone scan). Treatment can involve immobilization (boot, brace, or cast), pain management, and physical therapy. Surgery may be necessary for complex fractures or those involving the ankle.
- 19 Injury, poisoning and certain other consequences of external causes (S00-T88)
- S82.4 Fracture of shaft of fibulaS82 Fracture of lower leg, including ankleS82.40 Unspecified fracture of shaft of fibulaS82.401 Unspecified fracture of shaft of right fibulaS82.401A Unspecified fracture of shaft of right fibula, initial encounter for closed fracture
In simple words: A break in the right fibula bone in the lower leg. The skin is not broken. The doctor hasn't yet specified what kind of break it is.
A break in the long part of the right fibula (the smaller of the two lower leg bones) without specifying the exact type of fracture. This is for a closed fracture, meaning the bone did not break the skin.This code is used at the initial encounter.
Example 1: A patient presents to the ER after falling and injuring their right lower leg. X-rays reveal an unspecified fracture of the right fibula shaft. The skin is intact., A soccer player experiences pain in their right lower leg during a game. Imaging shows an unspecified fracture of the right fibula shaft, without any open wound., An elderly patient with osteoporosis trips and falls, resulting in an unspecified, closed fracture of the right fibula shaft.
Documentation should include the details of the injury, physical examination findings, imaging results, and treatment plan. The type of fracture (once specified) should be documented, as well as any associated injuries.It should also include that the patient is at an "initial encounter", meaning this is the first time they've sought care for this specific fracture.
- Specialties:Orthopedic Surgery, Emergency Medicine, Sports Medicine, Family Medicine, Internal Medicine
- Place of Service:Office, Home, Inpatient Hospital, On Campus-Outpatient Hospital, Emergency Room - Hospital,Outpatient Hospital,Ambulatory Surgical Center, Other Place of Service