S82.201D Unspecified fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing

ICD10CM code

#### Name of the Condition
- Unspecified fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing.
- Medical Term: Tibial shaft fracture.

#### Summary
A tibial shaft fracture refers to a break along the length of the tibia (shinbone), the larger of the two bones in the lower leg. This specific category addresses follow-up management of a closed fracture, where the skin around the fracture has not been opened or broken, and it is healing routinely after initial treatment.

#### Causes
- Direct trauma to the lower leg such as falls, car accidents, or sports injuries.
- Repetitive stress or overuse, especially in athletes.

#### Risk Factors
- High-impact sports participation.
- Osteoporosis or weak bones.
- Accidental falls, especially in older adults or those with balance issues.

#### Symptoms
- Intense pain at the site of the fracture.
- Swelling and tenderness along the shin.
- Difficulty standing or walking.
- Visible deformity in severe cases.

#### Diagnosis
- Physical examination by a healthcare provider.
- Imaging tests like X-rays or CT scans to confirm the fracture and assess alignment.

#### Treatment Options
- Immobilization with a cast or brace to support healing.
- Pain management with medications such as analgesics or anti-inflammatory drugs.
- Physical therapy to restore mobility and strength post-cast removal.
- Surgical intervention may be required in cases where alignment needs correction (although routine healing suggests this is not typically necessary here).

#### Prognosis and Follow-Up
- Most patients recover fully with proper treatment and adherence to rehabilitation plans.
- Routine follow-ups are essential to ensure proper healing and alignment.
- The prognosis is typically excellent with compliance to the guided treatment.

#### Complications
- Malunion or improper alignment of the bone during healing.
- Joint stiffness or chronic pain.
- In rare cases, compartment syndrome, which requires immediate attention.

#### Lifestyle & Prevention
- Engaging in strength-training exercises to improve bone density.
- Using protective gear while participating in sports.
- Ensuring a diet rich in calcium and vitamin D to maintain bone health.

#### When to Seek Professional Help
- Severe pain, numbness, or circulation problems in the affected limb.
- Signs of a returning deformity or worsening symptoms.
- Concerns about healing progress during follow-up visits.

#### Additional Resources
- American Academy of Orthopaedic Surgeons ([aaos.org](https://www.aaos.org)) for patient education on fracture healing.
- National Institutes of Health ([nih.gov](https://www.nih.gov)) for research and updates on bone health.

#### Tips for Medical Coders
- Ensure documentation specifies the right leg and confirms this is a subsequent encounter.
- Avoid confusion with open fractures or initial encounters; verify if the fracture is specified or remains unspecified.
- Double-check encounter specifics, such as whether it is a routine healing process.

Medical Policies and Guidelines for Unspecified fracture of shaft of right tibia, subsequent encounter for closed fracture with routine healing

Related policies from health plans

Similar Codes