2025 ICD-10-CM code S02.81
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Injury - Fractures of skull and facial bones Chapter 19: Injury, poisoning and certain other consequences of external causes Feed
Fracture of other specified skull and facial bones, right side.
Modifiers may be applicable depending on the circumstances of the encounter and the services provided.Consult the official coding guidelines for appropriate modifier usage.
The medical necessity for coding S02.81 is established by the presence of a fracture of other specified skull or facial bones on the right side. The documentation should support the diagnosis, including the mechanism of injury and the clinical findings, such as pain, swelling, deformity, and limitations in function.
Diagnosis and treatment of skull and facial bone fractures, including imaging (e.g., X-ray, CT scan), surgical intervention if necessary, pain management, and post-operative care.
- Chapter 19: Injury, poisoning and certain other consequences of external causes
- S00-S09 (Injuries to the head)
In simple words: This code is for a broken bone in the skull or face on the right side.It doesn't include specific breaks like those around the eye socket.The doctor will also need to add codes for any other injuries, such as a brain injury or if something is left inside the wound after the injury.
This ICD-10-CM code classifies a fracture affecting unspecified skull and facial bones on the right side of the body.It excludes fractures of the orbital floor, orbital roof, and requires additional coding for any associated intracranial injury (S06.-) or retained foreign body (Z18.-).The code may be further specified with 7th character extension to indicate the encounter (initial vs. subsequent) and the type of fracture (open vs. closed).
Example 1: A patient presents to the emergency department after a motor vehicle accident with a suspected right-sided zygomatic arch fracture.Imaging confirms the fracture, and the patient undergoes surgical repair., A patient falls and sustains a right-sided maxillary fracture.The fracture is managed conservatively with pain medication and close monitoring., A patient is involved in an assault and receives a right-sided nasal bone fracture.The patient undergoes closed reduction of the fracture.
Detailed medical history, including mechanism of injury.Complete physical examination documenting findings related to the fracture and associated injuries.Radiographic images (e.g., X-rays, CT scans) confirming the fracture location and extent.Operative report if surgical intervention was performed.Progress notes documenting post-operative course and any complications.
** This code should be used cautiously, as it is a relatively non-specific code.Efforts should always be made to use a more precise code when possible, if the specific bone fractured can be identified.
- Payment Status: Active
- Specialties:Emergency Medicine, Oral and Maxillofacial Surgery, Neurosurgery, Otolaryngology
- Place of Service:Emergency Room - Hospital, Office, Inpatient Hospital, Ambulatory Surgical Center