2025 ICD-10-CM code S02.81XG

This code signifies a subsequent encounter for a fracture of other specified skull and facial bones on the right side, characterized by delayed healing.

Follow the official ICD-10-CM coding guidelines provided by the Centers for Medicare & Medicaid Services (CMS).Ensure proper sequencing and documentation to support the code's use.Always code the most specific diagnosis possible.

Modifiers may be applicable depending on the specific circumstances of the encounter and the services performed. Consult the appropriate modifier guidelines for additional information.

Medical necessity for this code is established by the presence of a documented right-sided skull or facial bone fracture with objectively verifiable delayed healing.This necessitates ongoing medical management and/or intervention to promote proper healing and prevent complications. Documentation demonstrating the delayed healing must be present in the medical record.

The clinical responsibility encompasses the ongoing assessment and management of the fracture, including monitoring the healing process, evaluating the need for further intervention, and providing appropriate treatment to promote healing and manage complications.

IMPORTANT Consider additional codes from Chapter 20 (External causes of morbidity) to specify the cause of the injury.If a retained foreign body is present, code Z18.- should also be used.Excludes1: birth trauma (P10-P15), obstetric trauma (O70-O71). Excludes2: burns and corrosions (T20-T32), effects of foreign body in specified locations (T15.-, T16, T17.0-T17.3, T18.0), frostbite (T33-T34), venomous insect bite or sting (T63.4).

In simple words: This code is used for a follow-up visit to the doctor for a broken bone in the skull or face on the right side that is healing slower than expected.

S02.81XG is an ICD-10-CM code that denotes a subsequent encounter for a fracture of other specified skull and facial bones located on the right side of the body.The characteristic feature of this encounter is that the healing process is delayed.This code is used for situations where the initial fracture has been previously coded and the patient is now being seen for ongoing management of the delayed healing.

Example 1: A patient presents with a right-sided zygomatic fracture that was initially treated three weeks ago. The healing is progressing slower than expected, and the physician orders further imaging and discusses management options., A patient with a previously diagnosed right-sided temporal bone fracture returns for a follow-up visit. While the fracture is largely healed, there is evidence of delayed union, warranting further observation and potential intervention., A patient experiences a delayed healing process following a right-sided maxillofacial fracture surgery, which involves a complex fracture repair. A follow-up appointment is required to monitor the healing and rule out complications.

Medical record should include details of the initial injury, imaging reports demonstrating the fracture, documentation of previous treatments, and ongoing progress notes detailing healing status, interventions performed, and the physician's plan of care.Any complications should be thoroughly documented.

** This code is for subsequent encounters only.The initial encounter should be coded using the appropriate initial encounter codes (e.g., S02.81XA, S02.81XB).Always verify the laterality of the fracture to ensure correct coding.

  • Payment Status: Active
  • Specialties:Orthopedic Surgery, Neurosurgery, Oral and Maxillofacial Surgery, Plastic Surgery
  • Place of Service:Office, Hospital Inpatient, Hospital Outpatient, Ambulatory Surgical Center
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