2025 ICD-10-CM code S72.401H
(Active) Effective Date: N/A Injury, poisoning and certain other consequences of external causes - Injury to the hip and thigh 19 Feed
Unspecified fracture of the lower end of the right femur, subsequent encounter for open fracture type I or II with delayed healing.
Medical necessity for using this code is established by the presence of a documented open fracture of the distal right femur, type I or II, with objective evidence of delayed healing.The documentation should support the need for ongoing care and management of the fracture.
The physician is responsible for assessing the fracture, determining the cause of the delayed healing, and adjusting the treatment plan as needed. This may involve further imaging, consultation with specialists (e.g., orthopedics), pain management, and recommendations for physical therapy or other rehabilitation services.
In simple words: This code is used for a follow-up doctor's visit for a broken right thigh bone, just above the knee. The bone broke the skin and it's not healing as quickly as it should.
This code describes a follow-up visit for a patient who has a non-specific fracture at the bottom of their right thigh bone.The fracture is open, meaning the bone broke through the skin, and is classified as either type I or II according to the Gustilo open fracture classification. The healing process is taking longer than expected (delayed healing).
Example 1: A patient initially presented with an open fracture of the distal right femur, classified as Gustilo type II.The fracture was treated with surgical fixation. The patient returns for a follow-up visit several weeks later, and the physician notes that the fracture is not healing as expected. Code S72.401H is used., A patient experienced an open fracture of the lower end of the right femur in a motorcycle accident.The fracture site became infected, contributing to delayed healing. The patient returns for wound care and assessment of the fracture healing. Code S72.401H is used., A patient with a Gustilo type I open fracture of the distal right femur had initial treatment with antibiotics and immobilization.They present for a scheduled follow-up appointment. Imaging reveals the fracture healing is progressing slower than anticipated.Code S72.401H is applied.
Documentation should include the original injury date, type of open fracture (Gustilo classification), details of initial treatment, evidence of delayed healing (e.g., imaging results, physical exam findings), and the current treatment plan.
- Specialties:Orthopedic Surgery, Emergency Medicine, Family Medicine
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital, Office,Physician's Office