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Fracture of unspecified tarsal bone(s) of unspecified foot, initial encounter for closed fracture

ICD10CM code

Name of the Condition

  • Fracture of unspecified tarsal bone(s) of unspecified foot, initial encounter for closed fracture
  • Commonly referred to as a "closed tarsal bone fracture" or "tarsal fracture."

Summary

  • A tarsal fracture involves a break in one or more bones of the tarsus, located in the rearfoot and midfoot. This condition is typically due to trauma or injury and is characterized as a "closed fracture" when the skin remains intact.

Causes

  • Typically caused by significant trauma such as falls, sports injuries, or automobile accidents. Stress fractures can occur from repetitive use.

Risk Factors

  • Participation in high-impact sports or activities.
  • Osteoporosis or bone-weakening conditions.
  • Older age due to decreased bone density.
  • Previous foot injuries or fractures.

Symptoms

  • Swelling and tenderness in the affected foot.
  • Pain at the site of the fracture, worsening with weight-bearing activities.
  • Bruising and possible deformity of the foot.
  • Difficulty walking or inability to bear weight.

Diagnosis

  • Physical examination assessing pain and movement limitations.
  • Imaging tests such as X-rays, CT scans, or MRIs to visualize the fracture details.

Treatment Options

  • Immobilization using casts or splints to limit movement and promote healing.
  • Rest and elevation of the foot to reduce swelling.
  • Pain relief medications like NSAIDs.
  • In severe cases, surgical intervention may be necessary to realign the bones.

Prognosis and Follow-Up

  • With appropriate treatment, most fractures heal successfully in weeks to months.
  • Regular follow-ups to monitor the healing process and adjust treatment as needed.

Complications

  • If untreated, potential complications include chronic pain, deformity, and arthritis in the affected area.
  • Nonunion or malunion of the fracture may occur, requiring surgical intervention.

Lifestyle & Prevention

  • Wearing appropriate footwear to provide support during activities.
  • Strengthening exercises for foot and ankle support.
  • Calcium and vitamin D intake to maintain bone health.
  • Risk assessment and modification for older adults to prevent falls.

When to Seek Professional Help

  • Severe pain or swelling in the foot.
  • Inability to walk or bear weight on the affected foot.
  • Visible deformity or inability to move the foot.

Additional Resources

Tips for Medical Coders

  • Ensure specificity in documenting the fracture location and type (tarsal bone, closed fracture).
  • Double-check the designation for laterality and encounter nature to avoid common coding errors.
  • Verify the initial encounter status to distinguish from follow-up treatments or complications.

Medical Policies and Guidelines for Fracture of unspecified tarsal bone(s) of unspecified foot, initial encounter for closed fracture

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