2025 ICD-10-CM code S72.064M
(Valid) Effective Date: N/A Injury, poisoning and certain other consequences of external causes - Injury to the hip and thigh 19 Feed
Nondisplaced articular fracture of the right femoral head, subsequent encounter for open fracture type I or II with nonunion.
Medical necessity for subsequent care relates to the failed healing of the fracture (nonunion).Documentation should support the need for ongoing treatment, such as pain management, surgical intervention (e.g., revision surgery, bone grafting), or rehabilitation.
Diagnosis and treatment are typically managed by orthopedic surgeons or trauma specialists.Clinical responsibilities include physical examination, imaging studies (X-rays, CT, MRI), pain management, surgical intervention (if necessary), post-operative care, and rehabilitation.
In simple words: This code describes a follow-up visit for a specific type of hip fracture that hasn't healed properly. The fracture is in the ball part of the hip joint (femoral head), the bone pieces didn’t move out of place initially, and the skin was broken at the time of injury.Types I or II mean it wasn't the worst kind of open fracture."Nonunion" means the bone hasn't joined back together as it should.
Nondisplaced articular fracture of head of right femur, subsequent encounter for open fracture type I or II with nonunion.This refers to a break in the articular surface of the femoral head, where the bone fragments have not shifted out of alignment. It is classified as an open fracture type I or II according to the Gustilo classification, indicating minimal to moderate soft tissue damage.The code is used for a subsequent encounter, signifying that the fracture has failed to unite (nonunion).
Example 1: A patient initially sustained a nondisplaced articular fracture of the right femoral head, classified as Gustilo type II open fracture, in a motor vehicle accident three months prior.Follow-up X-rays show nonunion, and the patient presents for further evaluation and treatment options., A patient with osteoporosis falls and sustains an open type I fracture of the right femoral head. The fracture is treated initially, but at a follow-up appointment months later, imaging reveals that the bone has not healed and there is nonunion., A patient experiences a Gustilo type I open fracture of the right femoral head during a sporting event. The initial treatment involved stabilizing the fracture, but subsequent examinations demonstrate a lack of healing, indicating a nonunion.
Documentation should include the original injury date, type of open fracture (Gustilo classification), evidence of nonunion (e.g., imaging reports), details of subsequent encounters (dates, treatments provided), and the physician's assessment and plan.
** This code is for subsequent encounters related to the nonunion of the fracture. The initial encounter would be coded differently based on the open fracture type.
- Payment Status: Active
- Specialties:Orthopedic Surgery, Trauma Surgery
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital, Physician's Office