2025 ICD-10-CM code S02.81XK
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Injury - Fractures of skull and facial bones Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
This code represents a subsequent encounter for a fracture of other specified skull and facial bones on the right side, specifically where the fracture has not healed (nonunion).
Medical necessity for this code is established when there is a documented nonunion of a skull or facial bone fracture requiring additional medical management.This might include further imaging studies, additional orthopedic consultation, pain management, or surgical intervention to address the nonunion. The necessity should be clearly documented in the medical record.
The clinical responsibility for this code encompasses the initial diagnosis and treatment of the fracture, ongoing monitoring of the healing process, and management of complications related to the nonunion. This might include orthopedic consultation, imaging studies (X-rays, CT scans), and surgical intervention if necessary.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- S00-T88 (Injury, poisoning and certain other consequences of external causes) > S00-S09 (Injuries to the head)
In simple words: This medical code is used when someone has broken a bone in their skull or face (on the right side), and the broken bone hasn't healed properly after the initial injury.The doctor uses this code to track the patient's progress and provide further care for this unhealed fracture.
S02.81XK, from the ICD-10-CM classification, signifies a subsequent encounter for a fracture involving unspecified skull and facial bones located on the right side.The key characteristic is the nonunion of the fracture, indicating that the bone fragments have not joined together after the initial injury. This code is used for situations where the patient has already received initial treatment for the fracture and is now being seen for ongoing management or complications related to the nonunion.Additional codes may be necessary to capture any associated infections or retained foreign bodies.This code excludes birth trauma, obstetric trauma, burns, corrosions, and specific foreign body effects in the ear, larynx, mouth, nose, or pharynx. It also does not include frostbite or venomous insect bites.
Example 1: A patient presents to the emergency department after a motor vehicle accident with a fracture of the right zygomatic arch.Initial treatment is provided, and the fracture is documented as displaced.The patient is seen for follow-up after several weeks with imaging showing nonunion of the zygomatic arch.S02.81XK would be used for this subsequent encounter., A patient with a history of a right maxillary fracture that failed to heal properly is seen in an orthopedic clinic for evaluation and possible surgical intervention.Radiographic imaging confirms the nonunion, and the S02.81XK code is utilized., A patient falls and sustains a fracture of the right temporal bone with a nonunion noted on a CT scan weeks later. The physician uses S02.81XK in this clinical documentation.
Detailed documentation should include the initial injury date, mechanism of injury, initial treatment provided, dates of subsequent encounters, all imaging reports showing the fracture and its nonunion, treatment plans for the nonunion, and any complications encountered.
** Accurate coding requires detailed clinical documentation supporting the nonunion diagnosis.Use of this code implies a lack of healing in a previously fractured bone, requiring ongoing management.
- Payment Status: Active
- Specialties:Orthopedic Surgery, Neurosurgery, Oral and Maxillofacial Surgery, Emergency Medicine
- Place of Service:Office, Hospital (Inpatient and Outpatient), Emergency Room, Ambulatory Surgical Center