2025 ICD-10-CM code S02.1
(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 the base of the skull.
Modifiers may be applicable depending on the specific circumstances of the encounter and the services provided.
Medical necessity for the treatment of a skull base fracture is established by the presence of symptoms consistent with the fracture, such as headache, dizziness, visual disturbances, hearing loss, CSF rhinorrhea or otorrhea, and findings on imaging studies. The severity of the fracture and presence of any associated injuries will determine the medical necessity for surgical versus conservative management.The treatment plan must be clinically appropriate and meet payer guidelines.
Diagnosis and management of skull base fracture involves taking patient history, performing a thorough physical and neurological exam, ordering and interpreting imaging studies (X-rays, CT scans), and determining the appropriate treatment plan (medications or surgery). Post-operative care, if surgery is performed, is also a part of the clinical responsibility.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the head (S00-S09)
In simple words: A skull base fracture is a break in the bones at the bottom of the skull.This may not cause any symptoms or it might lead to swelling, bruising around the eyes or ears, or bleeding. Doctors diagnose it using a physical exam and imaging tests such as X-rays or CT scans. Treatment could involve pain relievers or surgery.
S02.1, Fracture of base of skull, in the ICD-10-CM classification system, denotes a fracture affecting the base of the skull.This involves a break in one or more bones forming the floor of the cranium. The injury may be asymptomatic or present with symptoms such as swelling, bruising around the eyes or ears, or bleeding at the fracture site. Diagnosis typically relies on patient history, physical examination (including neurological assessment), and imaging studies like X-rays or CT scans. Treatment options range from analgesic medication to surgical intervention, depending on the severity and nature of the fracture.Additional codes may be necessary to specify the type of fracture (open or closed), the encounter (initial or subsequent), and any associated injuries or complications, such as intracranial injuries.The use of secondary codes from Chapter 20 (External causes of morbidity) is recommended to specify the cause of the injury.If a foreign body is retained, additional coding with Z18.- is required.
Example 1: A 25-year-old male involved in a motor vehicle accident presents with severe headache, periorbital ecchymosis (raccoon eyes), and Battle's sign (bruising behind the ear). CT scan reveals a fracture of the base of the skull. He is admitted for observation and management of his injuries., A 60-year-old female falls and hits her head.She is alert and oriented but complains of dizziness and mild headache.A CT scan shows a small, non-displaced fracture of the base of the skull.She is discharged with instructions for rest and pain medication., A 10-year-old child sustains a skull base fracture after falling from a tree.She has CSF rhinorrhea (leakage of cerebrospinal fluid from the nose) and requires surgical repair of the fracture to prevent further complications such as meningitis.
Detailed patient history including the mechanism of injury; physical examination findings, including neurological assessment; imaging studies (X-rays or CT scans) demonstrating the fracture; documentation of any associated injuries; treatment plan and response to treatment; and discharge instructions.
** This code is for the fracture itself.Separate codes are necessary for any associated injuries, complications, or procedures.
- Payment Status: Active
- Specialties:Emergency Medicine, Neurosurgery, Otolaryngology
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, Ambulatory Surgical Center