2025 ICD-10-CM code S02.81XD
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Injury - Fracture of other specified skull and facial bones Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Subsequent encounter for fracture of other specified skull and facial bones on the right side with routine healing.
Medical necessity for subsequent encounters is established by the need for ongoing monitoring of fracture healing to detect and manage complications.The clinical documentation must justify the need for the follow-up visit, based on the complexity of the fracture and the patient’s overall status.
The clinical responsibility involves monitoring the healing process of the fracture, assessing for complications, and providing appropriate post-fracture care.This may include pain management, wound care if present, and evaluating the patient's functional recovery.If complications arise, additional treatment and coding would be necessary.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- S00-S09 (Injuries to the head)
In simple words: This code is used for a follow-up visit after a broken bone in the skull or face (on the right side). The bone is healing normally.
This ICD-10-CM code signifies a subsequent encounter for a fracture involving unspecified skull and facial bones located on the right side of the body.The healing process is documented as routine, indicating no significant complications or delays.
Example 1: A patient presents for a follow-up appointment two weeks after a right-sided zygomatic fracture repair. The fracture is healing as expected, and the patient reports minimal discomfort.S02.81XD is used to code this routine healing subsequent encounter., A patient returns six weeks post-op following a right-sided nasal bone fracture. The bone shows signs of proper alignment and healing. The surgeon documents the healing as routine.S02.81XD is the appropriate code., A patient had a complex comminuted fracture of the right maxilla.After multiple surgeries and a prolonged healing process with no complications, the patient returns for a routine checkup showing complete bone healing. S02.81XD can be used to code this.
Detailed medical records should include the initial diagnosis and treatment of the fracture, the date of injury, radiographic imaging (before and after treatment showing healing), progress notes documenting the healing process, and the physician's assessment confirming routine healing.The specific bone fractured needs to be documented, although unspecified.The right side location is necessary.
** This code is for subsequent encounters.The initial encounter for the fracture should be coded separately using a different code from the S02 series.The use of this code implies that the initial fracture has been previously coded.
- Payment Status: Active
- Specialties:Orthopedic Surgery, Plastic Surgery, Oral and Maxillofacial Surgery, Emergency Medicine
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center