2025 ICD-10-CM code S02.81XA

Fracture of other specified skull and facial bones, right side, initial encounter for closed fracture.

Use additional codes from Chapter 20 (External causes of morbidity) to identify the cause of the injury. If a foreign body is present, use code Z18.-.

Modifiers may be applicable depending on the specific circumstances of the encounter, such as the place of service or type of anesthesia used.Consult the appropriate modifier guidelines for specific situations.

Medical necessity for coding S02.81XA is established when a right-sided closed fracture of the skull or facial bones is clinically diagnosed, requiring medical attention. This would involve appropriate clinical evaluation to establish a diagnosis, which includes conducting imaging such as X-rays, CT scans, etc.

The clinical responsibility involves diagnosing the fracture, determining its extent and severity, managing pain, and potentially recommending or performing surgical intervention or other treatments.Post-operative care and follow-up are also part of the clinical responsibility, depending on the severity and treatment plan.

IMPORTANT Related codes include those for fractures of specific skull and facial bones (e.g., S02.1, S02.2, S02.3, etc.), open fractures (indicated by adding "B" to the code), subsequent encounters (indicated by adding "D", "G", or "K"), and associated intracranial injuries (S06.-).

In simple words: This code describes a first-time visit to a doctor for a broken bone in the skull or face on the right side of the head, without an open wound. The doctor will need more information to specify exactly which bone is broken.

This code signifies the initial encounter for a closed fracture affecting unspecified skull and facial bones on the right side of the body.It is crucial to document the specific bone(s) involved and any associated injuries or complications.Additional codes should be used to identify any retained foreign bodies (Z18.-) and the cause of the injury (Chapter 20, External causes of morbidity).

Example 1: A patient presents to the emergency room after a motor vehicle accident with facial pain and swelling.A CT scan reveals a closed fracture of the zygomatic arch on the right side.Code S02.81XA is used., A patient falls and hits their head, resulting in a closed fracture of the right temporal bone. Code S02.81XA is applied, with additional codes to specify the fracture location and any intracranial injury., A patient sustains a right-sided facial fracture during a sports injury.After initial treatment, they require a follow-up visit for assessment of healing. A subsequent encounter code (e.g., S02.81XD, S02.81XG, or S02.81XK) would then be used, depending on the status of healing.

Detailed medical history, physical examination findings, imaging reports (X-rays, CT scans), operative reports (if applicable), and progress notes documenting the treatment and follow-up care are required.

** This code is for initial encounters only.Subsequent encounters require different codes (S02.81XD, S02.81XG, S02.81XK) depending on the healing process. Always specify the exact location of the fracture if possible, and use additional codes to capture any associated injuries, such as intracranial hemorrhage or damage to surrounding structures.

  • Payment Status: Active
  • Specialties:Emergency Medicine, Neurosurgery, Oral and Maxillofacial Surgery, Plastic Surgery
  • Place of Service:Emergency Room - Hospital, Office, Inpatient Hospital, Ambulatory Surgical Center
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