ICD-10 code S82.191B: Upper end right tibia open fracture

Key takeaways

S82.191B is a billable ICD-10-CM code for other fracture of upper end of right tibia, initial encounter for open fracture type I or II

The 7th character B covers Gustilo type I and type II wounds, while type IIIA, IIIB, and IIIC take C

B is also the default 7th character when the record documents an open fracture without a Gustilo type

The common error is assigning B to a type III wound, which understates severity and invites a denial

Pabau’s claims management software supports accurate ICD-10 code submission and reduces claim errors for orthopedic and trauma practices

S82.191B is a valid, billable ICD-10-CM diagnosis code. Its full long description is: Other fracture of upper end of right tibia, initial encounter for open fracture type I or II. The short description is: Oth fx upper end of right tibia, init for opn fx type I/2.

The B in the 7th position is a Gustilo grade, not a general open-fracture flag. It covers type I and type II wounds. A type IIIA, IIIB, or IIIC open fracture at the same site is coded S82.191C instead.

Understanding the 7th character in ICD-10 code S82.191B

The 7th character is where most S82.191 coding errors happen. It specifies the encounter type, meaning initial, subsequent, or sequela. For open fractures it also carries the Gustilo grade. Selecting the wrong character sends the wrong encounter type to the payer and can trigger a denial or audit.

The full S82.191 family covers every encounter type and fracture-openness combination. The table below lists all valid 7th character options.

Key distinction: The 7th character B applies to Gustilo type I and type II open fractures. A type IIIA, IIIB, or IIIC open fracture uses 7th character C instead. Confusing the two misstates injury severity and creates a billing error with audit implications.

The same split runs through the whole family. Characters B, E, H, M and Q all mean type I or II, while C, F, J, N and R all mean type III. The same lettering carries into neighboring subcategories, so the Q in S82.499Q also means type I or II.

How the Gustilo classification decides between B and C

The Gustilo-Anderson classification is the standard framework for grading open fractures. The 7th character B in S82.191B maps to the two lowest tiers of that classification. Understanding the criteria is essential for selecting the correct code.

The Gustilo criteria above are based on the widely accepted classification system described in orthopedic surgery literature (Gustilo and Anderson, 1976; Gustilo et al., 1984). Verify wound size and soft tissue characteristics against the surgeon’s operative note before selecting the 7th character.

The default in the last row is why B is the more common of the two codes in practice. The ICD-10-CM Official Guidelines instruct coders to assign the type I or II character when an open fracture carries no documented Gustilo grade.

That default is safe for billing and misleading for severity. A type III wound left ungraded still ends up coded as S82.191B.

What counts as the upper end of the right tibia

The “upper end” of the tibia refers to the proximal region. That region covers the tibial plateau, the medial and lateral condyles, and the area immediately below the knee joint.

S82.191B applies to fractures of this zone on the right side. Coders working in a physical therapy EMR meet the code again during post-acute rehabilitation billing.

Per the WHO ICD-10 browser, the parent code S82.1 (Fracture of upper end of tibia) explicitly includes:

• Condylar fractures of the tibia
• Fractures of the proximal tibia

The ICD-10-CM Excludes2 notes at this level point you elsewhere for injuries outside the upper end of the tibia:

• S82.2- – Fracture of shaft of tibia
• S89.0- – Physeal fracture of upper end of tibia
• S92.- – Fracture of foot, except ankle
• M97.1- – Periprosthetic fracture around an internal prosthetic knee joint
• M97.2 – Periprosthetic fracture around an internal prosthetic ankle joint

Laterality matters just as much. Do not use S82.191B for a left-tibia injury, since left-sided upper tibial fractures have their own codes under S82.19.

Code hierarchy and parent code for S82.191B

S82.191B sits within a well-defined hierarchy. Knowing the parent structure helps when a patient arrives with several injuries and you need a neighboring code such as S72.309N.

• S00-T88 – Injury, poisoning and certain other consequences of external causes (chapter)
• S80-S89 – Injuries to the knee and lower leg (block)
• S82 – Fracture of lower leg, including ankle
• S82.1 – Fracture of upper end of tibia
• S82.19 – Other fracture of upper end of tibia
• S82.191 – Other fracture of upper end of right tibia (6-character parent)
• S82.191B – Initial encounter, open fracture type I or II (billable 7-character code)

Approximate synonyms for ICD-10 code S82.191B

Clinical documentation rarely uses the exact ICD-10-CM long description. Coders need to recognize the following terms as mapping to S82.191B when the 7th character context is correct.

• Open fracture of upper end of right tibia, type I (initial encounter)
• Open fracture of proximal right tibia, Gustilo type II (initial encounter)
• Open fracture of right tibial plateau (Gustilo I or II, initial)
• Open condylar fracture of right tibia, initial encounter, type I or II
• Right proximal tibia fracture, open type II, initial encounter
• Right upper tibial fracture with open wound, Gustilo type not stated, initial

None of these synonyms are valid substitutes for S82.191B if the Gustilo type is IIIA, IIIB, or IIIC – that encounter maps to S82.191C.

Associated CPT codes for open tibial fracture repair

Diagnosis code S82.191B is submitted alongside CPT procedure codes that reflect the surgical management of the open fracture. The pairing depends on the operative technique documented by the surgeon. Orthopedic and trauma practices using sports medicine practice software will typically encounter these CPT codes in combination with S82.191B.

CPT pairings should reflect the documented operative technique. A single-plane frame is coded 20690 rather than 20692. Confirm each selection against the surgeon’s operative report before claim submission. Refer to the AAPC ICD-10-CM code lookup for crosswalk validation between diagnosis and procedure codes.

Coding and documentation guidelines for S82.191B

Accurate coding for S82.191B requires documentation that supports every element of the code. The CMS ICD-10-CM coding guidelines govern how fracture codes are assigned. The Official Guidelines for Coding and Reporting then set the rules for laterality, encounter type, and the open versus closed split.

Capture those elements before the claim leaves your practice. The same record then supports the bill and any later audit, which is what HIPAA compliance asks of your documentation.

• Laterality: The code is right-tibia specific. Verify the operative or radiology report explicitly states the right side before assigning S82.191B.
• Open vs closed: The operative or emergency department note must document the fracture as open. A closed fracture of the same site uses S82.191A.
• Gustilo type: The Gustilo classification should appear in the operative note. Where it is absent, the guidelines default the 7th character to B, which can understate a type III injury.
• Encounter type: Use 7th character B only for the initial encounter, meaning the patient is receiving active treatment for the fracture. Subsequent encounters use D through R, and sequela conditions use S.
• Multiple injuries: When S82.191B is coded alongside other injuries, sequence the most severe injury first per CMS guidance. Follow the guidelines instead where they direct otherwise for the specific claim type.

Standardized clinical documentation forms can capture wound classification and laterality on every trauma encounter. Verify code applicability each year against the CDC/NCHS ICD-10-CM tool. Code validity dates change every October 1.

How Pabau supports ICD-10 diagnostic coding workflows

Claim errors on open fracture codes usually trace back to documentation workflows rather than coder knowledge. When the surgeon’s note does not state a Gustilo type, the coder falls back to the type I or II character. That fallback is defensible, but it can understate a type III injury and invite a denial on review.

Practice management software like Pabau keeps ICD-10 diagnostic codes and their associated CPT codes linked to the clinical encounter record. Our claims management software shortens the distance between what the surgeon documented and what the biller submits. Fewer claims then go out on an assumed 7th character.

Pabau’s patient record management captures structured clinical data at the point of care. Wound classification, laterality, and encounter type are then available to the billing team without anyone chasing down operative notes.

Pabau Scribe, our AI scribe, structures encounter documentation so the wound grade and the side are easy to find. Good EHR integration means coders and clinicians work from one data source. That removes the transcription errors behind 7th character mismatches.

Reduce claim errors on open fracture cases

Pabau’s claims management software helps orthopedic and trauma practices submit accurate ICD-10 diagnosis codes and paired CPT codes. That cuts denials caused by 7th character mismatches and thin operative documentation.

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Conclusion

S82.191B lives or dies on one letter, and that letter comes from the operative note. Where the surgeon grades the wound, the choice between B and C is straightforward. Where nobody grades it, the default quietly files a type III injury as a type I or II.

So the fix sits upstream of the biller. Make the Gustilo grade a required field on every open fracture note, and the 7th character stops being a judgment call. The severity mismatches that draw audit attention go with it.

Pabau’s claims management software connects clinical documentation directly to the billing workflow, so fewer claims go out on an assumed 7th character. To see how Pabau handles ICD-10 coding in orthopedic and trauma practices, book a demo.

Continue your research

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Tracking recovery after fracture fixation? The functional status questionnaire records patient-reported progress your billing team can cite.

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