2025 ICD-10-CM code S42.301B
(Valid) Effective Date: N/A Injury, poisoning and certain other consequences of external causes - Fracture of upper arm 19 Feed
Unspecified fracture of shaft of humerus, right arm, initial encounter for open fracture.
Medical necessity is established by the presence of a fracture confirmed by imaging.The documentation should support the need for the treatment provided, whether it is conservative management or surgical intervention. The open nature of the fracture increases the risk of infection and typically necessitates more urgent care.
The physician is responsible for diagnosing the fracture through physical examination, imaging (X-ray, CT, MRI), and potentially nerve conduction studies. Treatment might include pain management, immobilization (splint, cast), reduction (if necessary), and possibly surgery.Follow-up care and physical therapy would likely be required.
In simple words: This code represents a break in the middle part of your right upper arm bone where the bone has broken through the skin.This is the first time you are being seen for this injury.The doctor hasn't yet determined the specific type of break.
This code describes an open fracture of the shaft of the right humerus.The documentation does not specify the exact type of fracture (e.g., transverse, spiral, comminuted) and it is the patient's initial encounter for this injury. An "open" fracture indicates that the broken bone has pierced the skin.
Example 1: A 25-year-old male presents to the ER after a motorcycle accident with a protruding bone through the skin of his right upper arm.Imaging confirms a fracture of the humeral shaft., A 60-year-old female tripped and fell, landing on her outstretched right arm.She has a deep laceration on her upper arm with visible bone fragments.X-rays confirm an open humeral shaft fracture., A 12-year-old boy fell from a tree, landing on his right arm. He has a bleeding wound on his upper arm, and the bone is visible. Imaging confirms an open fracture of the humeral shaft.
Documentation should include the location of the fracture (right humeral shaft), the fact that it is open, the mechanism of injury, associated injuries, and treatment provided.Details of the wound, neurovascular status, and any complications should also be documented.
- Specialties:Orthopedic Surgery, Emergency Medicine, Trauma Surgery, General Surgery
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, Office, Outpatient Hospital, Urgent Care Facility