M19.011 - Primary osteoarthritis, right shoulder

Clinical Definition

A displaced fracture occurs when bone fragments at the break site are separated and misaligned. In a bimalleolar ankle fracture, both the medial (inside) and lateral (outside) malleoli are broken, significantly compromising ankle stability.

Documentation Requirements

• Laterality:

  • Must specify right or left ankle

  • Cannot use "bilateral" as each ankle requires separate coding

• Displacement Status:

  • Document if displaced or nondisplaced

  • Include degree/direction of displacement if relevant

• Healing Status:

  • Routine (standard healing)

  • Delayed healing

  • Nonunion

  • Malunion

• Encounter Type:

  • Initial encounter

  • Subsequent encounter

  • Sequela

Common Synonyms

• "Broken ankle on both sides"

• "Double break in ankle"

• "Two-point ankle fracture"

• "Broken inside and outside of ankle"

Coding Conflicts

Excludes1:

• Trimalleolar fractures

• Pilon fractures of tibia
  Excludes2:

• Isolated medial malleolus fracture

• Isolated lateral malleolus fracture

Scribing.io Automation

The AI scribe automatically identifies and tags key phrases like "bimalleolar fracture," "displaced," and anatomical descriptors in the natural conversation. It maps conversational language ("broken on both sides of ankle") to proper medical terminology and ensures all required elements (laterality, displacement, healing status) are captured for accurate coding.