2025 ICD-10-CM code S89.102A
(Active) Effective Date: N/A Injury, poisoning and certain other consequences of external causes - Injury to the knee and lower leg 19 Feed
Unspecified physeal fracture of lower end of left tibia, initial encounter for closed fracture.
Medical necessity is established by the presence of a closed, unspecified physeal fracture at the lower end of the left tibia. The initial encounter usually requires evaluation, pain management, immobilization or splinting, and follow-up care. The need for any procedures or further treatment must be clinically justified and documented.
In simple words: This code represents a break in the growth plate at the bottom of the left shinbone (tibia) where the details of the break aren't specified. This is the patient's first visit for this closed fracture (meaning the bone hasn't broken through the skin).
Unspecified physeal fracture of lower end of left tibia, initial encounter for closed fracture.
Example 1: A 10-year-old boy falls while playing soccer and injures his left knee. X-rays reveal an unspecified physeal fracture of the lower end of his left tibia. The skin is intact. This is his first visit for this injury., A 16-year-old girl sustains a twisting injury to her left knee while snowboarding. Imaging studies indicate an unspecified physeal fracture of the distal left tibia. The fracture is closed. This is her initial encounter for this injury., A child presents to the emergency room after falling from a swing set. Physical examination and X-rays confirm a closed, unspecified physeal fracture of the lower end of the left tibia. It's the child's first time seeking medical care for this injury.
Diagnosis must be supported by clinical findings and imaging studies (such as X-rays) that clearly document an unspecified physeal fracture at the lower end of the left tibia. The documentation should also confirm that the fracture is closed and that this is the initial encounter for this injury. If there are any other injuries, they need to be documented separately.
** "Physeal" refers to the growth plate, which is a layer of cartilage near the end of long bones in children and adolescents. Because this area is still actively growing, it is more susceptible to fracture.
- Specialties: Orthopedic Surgery, Pediatric Orthopedics, Emergency Medicine, Family Medicine, Sports Medicine
- Place of Service: Office, Emergency Room - Hospital, Urgent Care Facility, Inpatient Hospital, Outpatient Hospital, On Campus-Outpatient Hospital