2025 ICD-10-CM code S72.454B
(Active) Effective Date: N/A Injury, poisoning and certain other consequences of external causes - Injury to the hip and thigh 19 Feed
Nondisplaced supracondylar fracture without intracondylar extension of the lower end of the right femur, initial encounter for open fracture type I or II.
Medical necessity is established by the presence of a fracture requiring treatment to restore function and prevent complications. Open fractures require prompt attention due to the risk of infection.
Diagnosis involves physical examination, imaging (X-ray, CT, MRI), and possibly lab tests. Treatment may range from casting and traction (especially in young children) to surgical stabilization with open reduction and internal fixation (ORIF), followed by physical therapy.
In simple words: A break in the right thigh bone, just above the knee, where the bone pieces haven't shifted out of place.There's a small cut or tear in the skin near the break.This is the patient's first visit for this injury.
Nondisplaced supracondylar fracture without intracondylar extension of the lower end of the right femur. This signifies a break in the femur (thigh bone) just above the knee joint's condyles, without displacement of the fractured fragments.It is classified as an open fracture type I or II according to the Gustilo classification, indicating a tear in the skin exposing the fracture, typically due to minimal to moderate soft tissue damage. This code is used for the initial encounter.
Example 1: A 10-year-old boy falls from a tree and sustains an open fracture of his right distal femur, just above the condyles, with a small laceration. X-rays confirm a nondisplaced supracondylar fracture without intracondylar extension., A 25-year-old female is involved in a motor vehicle accident. She has a deep abrasion over her right knee and pain in her thigh.Examination and imaging reveal an open, type II, nondisplaced supracondylar fracture without intracondylar extension of her right femur., A 60-year-old male trips and falls, sustaining an open fracture to his right distal femur.Evaluation shows a nondisplaced supracondylar fracture without intracondylar extension, classified as Gustilo type I due to minimal skin damage.
Documentation should include details of the injury mechanism, physical exam findings (e.g., location of fracture, presence and size of wound, neurovascular status), imaging results, and type of open fracture (Gustilo classification).
** This code applies to the initial encounter.Subsequent encounters for this fracture would use a different code.It is important to distinguish this fracture from those involving intracondylar extension (S72.46-) or physeal fractures (S79.1-), which have different codes.
- Specialties:Orthopedic Surgery, Emergency Medicine, Trauma Surgery
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, Outpatient Hospital, Office