2025 ICD-10-CM code S72.001R
(Active) Effective Date: N/A Injury, poisoning and certain other consequences of external causes - Injuries to the hip and thigh 19 Feed
Fracture of an unspecified part of the neck of the right femur, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion.
Medical necessity is established by the presence of a documented open femoral neck fracture with malunion causing functional impairment, pain, or other complications.
Diagnosis involves physical exam, imaging (X-ray, CT, MRI, bone scan), and lab tests to assess blood loss, clotting, muscle injury. Treatment ranges from casting/splinting for stable fractures to surgical reduction and fixation for unstable or open fractures. Pain management and physical therapy are also important.
In simple words: This code refers to a follow-up visit for a badly healed broken right hip. The break was severe, went through the skin, and didn't heal straight.
This code describes a break in the neck of the right femur, an area between the head and shaft of the thigh bone.It is a subsequent encounter, meaning the patient has been seen for this fracture before. The fracture is open, meaning the bone broke through the skin.It is classified as type IIIA, IIIB, or IIIC according to the Gustilo classification, indicating significant soft tissue damage and potential vascular or nerve injury.The fracture has healed with malunion, meaning the bones haven't healed in proper alignment.
Example 1: A patient initially sustained an open fracture of the right femoral neck in a motorcycle accident, classified as Gustilo type IIIB. After surgical intervention, they are now presenting for a follow-up visit due to ongoing pain and limited mobility. Imaging reveals the fracture has healed in a malaligned position., An elderly patient with osteoporosis fell and sustained a right femoral neck fracture, which pierced the skin due to bone fragility. The initial injury was classified as Gustilo type IIIA.Months later, the patient has difficulty walking due to persistent pain and malunion is confirmed radiographically during a subsequent encounter., A patient with a history of bone cancer had a pathological open fracture of their right femoral neck after a minor fall.The fracture was classified as Gustilo type IIIC due to extensive soft tissue involvement. Following surgery, the patient is now seen for a follow-up appointment where imaging reveals malunion of the fracture.
Documentation should include details of the initial injury, type of open fracture (Gustilo classification), treatment provided, evidence of malunion (e.g., imaging reports), current symptoms, and functional limitations.
- Payment Status: Active
- Specialties:Orthopedic Surgery, Trauma Surgery
- Place of Service:Office, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital