2025 ICD-10-CM code S02.81XB

Open fracture of other specified skull and facial bones, right side, initial encounter.

Use secondary codes from Chapter 20 (External causes of morbidity) to specify the cause of the injury.Also, code any associated intracranial injury (S06.-) or retained foreign body (Z18.-).

Medical necessity for this code is established by the presence of a confirmed open fracture requiring medical intervention.This often includes pain management, wound care, reduction of the fracture (if necessary), and potential surgical repair or antibiotic prophylaxis.

Clinical responsibility for this code typically falls upon the physician providing initial evaluation and management of the fracture, potentially including specialists such as emergency medicine physicians, trauma surgeons, oral and maxillofacial surgeons, or plastic surgeons.

In simple words: Open fracture of other facial bones on the right side, first visit.

Fracture of other specified skull and facial bones, right side, initial encounter for open fracture. This code describes a break in one or more bones of the skull or face on the right side, excluding specific fractures like those of the orbital floor or roof.The fracture site is open, meaning the bone has pierced the skin, creating a direct communication between the fracture and the external environment. This is an initial encounter, meaning it is the first time the patient is receiving care for this specific injury.

Example 1: A patient presents to the emergency room after being struck on the right side of the face by a baseball bat. Imaging reveals an open fracture of the zygomatic bone (cheekbone)., A cyclist crashes and sustains an open fracture of the right temporal bone.The injury is noted to be open due to a laceration directly over the fracture site., A patient arrives at the urgent care clinic with an open fracture of the right nasal bone following a fistfight. The broken bone is visible through a cut in the skin.

Documentation should include details of the injury mechanism, physical exam findings (including description of the open wound), imaging results confirming the fracture and its location, and associated injuries.

** Excludes1: birth trauma (P10-P15), obstetric trauma (O70-O71). Excludes2: burns and corrosions (T20-T32), effects of foreign body in ear (T16), etc.See complete list of excludes2 in ICD-10-CM guidelines.

  • Specialties:Emergency Medicine, Trauma Surgery, Oral and Maxillofacial Surgery, Plastic Surgery
  • Place of Service:Emergency Room - Hospital, Office, Inpatient Hospital, Outpatient Hospital, Urgent Care Facility
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