2025 ICD-10-CM code S02
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Injury - Injuries to the head Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Fracture of skull and facial bones.Code also for any associated intracranial injury.
Modifiers may apply depending on the specific circumstances of the procedure (e.g., location, anesthesia). Refer to the current CPT and modifier guidelines.
Medical necessity is established based on the severity of the fracture, associated injuries, and the need for intervention to prevent complications such as intracranial hemorrhage, infection, or cosmetic deformity.Documentation supporting the medical necessity of treatment should be thorough.
Diagnosis is based on patient history, physical examination (including neurological exam), and imaging (X-ray or CT scan). Treatment may involve analgesics, antiseizure medication, or surgery.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the head (S00-S09)
In simple words: This code means a broken bone in the skull or face.It's important to also note any other injuries to the brain.
This code represents a fracture of the skull and facial bones.It encompasses breaks in the bones of the cranium (skull) and the bones of the face. The code should also include any associated intracranial injury (S06.-).A fracture not indicated as open or closed should be coded as closed.Additional codes from Chapter 20 (External causes of morbidity) are used to specify the cause of the injury.If a retained foreign body is present, this should be coded using Z18.-.
Example 1: A patient presents after a motor vehicle accident with facial swelling, pain, and nasal bleeding. CT scan reveals a comminuted fracture of the zygomatic arch and a linear fracture of the frontal bone., A child falls from a tree and sustains a depressed skull fracture above the right temple.There is visible deformity and the patient is experiencing altered mental status. , An elderly patient falls and fractures their mandible. They present with difficulty chewing and speaking. Panoramic X-rays reveal a displaced fracture of the mandibular body.
Detailed patient history of the injury mechanism, physical examination findings (including neurological assessment), and radiological imaging (CT scan, X-rays).Documentation should also include the treatment plan (conservative vs. surgical), any complications, and the patient's response to treatment.
** This code can be used for fractures of various skull and facial bones.Accurate coding requires detailed documentation of the injury, associated findings, and treatment provided.
- Payment Status: Active
- Specialties:Emergency Medicine, Neurosurgery, Oral and Maxillofacial Surgery
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, Office