2025 ICD-10-CM code S02.82XD

Subsequent encounter for fracture of other specified skull and facial bones on the left side with routine healing.

Refer to the official ICD-10-CM coding guidelines for detailed instructions on the use of this code, especially concerning subsequent encounters and the use of additional codes to specify the cause of injury or associated conditions.

Medical necessity is established by the need for follow-up care after a fracture to monitor healing, detect and treat complications, and provide appropriate rehabilitation or ongoing management.The physician's documentation should justify the need for this subsequent visit, based on clinical findings, and this must be in compliance with payer requirements.

The clinical responsibility encompasses the assessment of the healing fracture, evaluation of any potential complications, and planning for further management or rehabilitation. The physician monitors the healing process, addresses any pain or functional limitations, and provides instructions for continued care.

IMPORTANT Consider additional codes from Chapter 20 (External causes of morbidity) to specify the cause of the injury.Also code any associated infection.Related codes include S02.82XG (delayed healing), S02.82XK (nonunion), and S02.82XS (sequela).

In simple words: This code is for a follow-up visit after a broken bone in the skull or face (on the left side) has healed normally.

This ICD-10-CM code signifies a subsequent encounter for a fracture affecting unspecified skull and facial bones on the left side, characterized by routine healing.It indicates that the patient is undergoing follow-up care after an initial fracture treatment, and the healing process is progressing as expected without complications. This code is used for coding purposes only after the initial fracture encounter has already been coded.

Example 1: A patient presents for a follow-up appointment three weeks after a left-sided zygomatic fracture.The fracture shows signs of routine healing, without complications such as infection or malunion.S02.82XD is used to code this encounter. , A patient who previously suffered a left-sided nasal bone fracture returns for a routine check-up six weeks post-injury. The fracture has healed without significant complications. S02.82XD accurately reflects the patient's condition during this visit., A patient had a left-sided maxilla fracture treated in an emergency room; they were referred to an orthopedic surgeon, who now sees the patient in follow-up for assessment. The fracture is healing normally.S02.82XD is coded.

Medical records should include the initial diagnosis of fracture, imaging studies (e.g., X-rays, CT scans) documenting the fracture and subsequent healing progress, notes from the physician documenting the assessment at the subsequent encounter, and any other relevant clinical details such as patient's symptoms or physical examination findings.

** If the healing is not routine (e.g., delayed healing, nonunion), use the appropriate code from the S02.82X series (S02.82XG, S02.82XK).

  • Payment Status: Active
  • Specialties:Orthopedics, Oral and Maxillofacial Surgery, Emergency Medicine
  • Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center
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