2025 ICD-10-CM code S42.301
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Injury - Injuries to the shoulder and upper arm Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Unspecified fracture of the humerus shaft in the right arm.
Medical necessity for treatment is established through the patient's clinical presentation, imaging findings demonstrating a fracture, and the potential for impairment of function if left untreated.The choice between surgical and non-operative treatment is determined by the severity and specific characteristics of the fracture.
Diagnosis and treatment of this fracture involves patient history, physical examination, imaging (X-ray, CT, MRI), and potentially nerve conduction studies. Treatment options range from non-operative management (sling, cast, immobilization) to surgical intervention (open reduction, internal fixation) depending on the severity and displacement of the fracture. Post-operative care may include pain management, physical therapy, and monitoring for complications.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the shoulder and upper arm (S40-S49)
In simple words: This code describes a break in the middle part of the upper arm bone (humerus) on the right side. The doctor doesn't specify the exact type of break.
This code signifies an unspecified fracture of the humeral shaft in the right arm.The fracture location is the diaphysis (shaft) of the humerus, the long bone in the upper arm. The specific type of fracture (e.g., transverse, oblique, spiral, comminuted) is not specified. The injury may involve displacement of bone fragments, but this is also not specified.Associated injuries, such as nerve damage or vascular compromise, are not included in this code but should be coded separately.The code is used when the provider's documentation does not specify the precise nature of the humeral shaft fracture.
Example 1: A patient falls from a height, sustaining a fracture of the right humeral shaft. Imaging reveals a displaced fracture with no evidence of nerve damage. The patient undergoes closed reduction and casting., A motor vehicle accident results in a comminuted fracture of the right humeral shaft and radial nerve palsy. The patient requires surgical open reduction and internal fixation, along with nerve exploration and repair., An athlete suffers a nondisplaced fracture of the right humeral shaft during a sports activity.Conservative treatment with a sling and immobilizer is sufficient.
Detailed documentation should include the mechanism of injury, physical examination findings, imaging reports, details about fracture displacement and alignment, any associated injuries (e.g., nerve injury), surgical procedures performed (if any), and the post-operative course.
** This code is frequently used in conjunction with other codes to provide a more comprehensive picture of the patient's condition.Precise documentation is crucial for accurate coding.
- Payment Status: Active
- Specialties:Orthopedics, Emergency Medicine, Trauma Surgery
- Place of Service:Emergency Room - Hospital, Office, Inpatient Hospital, Ambulatory Surgical Center