2025 ICD-10-CM code S52.332N

Displaced oblique fracture of the shaft of the left radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion.

Appropriate coding requires precise classification of the fracture type (Gustilo classification) and documentation of nonunion.Secondary codes from Chapter 20 (External Causes) should be used to identify the mechanism of injury.A code for any retained foreign body should also be added if applicable (Z18.-).

Modifiers may be used to indicate the type of service provided (e.g., subsequent encounter, surgical revision).Specific modifier selection depends on the circumstances of the visit and should align with payer-specific guidelines.

Medical necessity for subsequent encounters is established by the presence of a nonunion after prior treatment of an open fracture.The physician's documentation should demonstrate the continued need for treatment to achieve fracture union, considering the potential for long-term complications related to nonunion, such as pain, instability, and functional impairment.

The clinical responsibility includes diagnosis through patient history, physical examination, and imaging (X-rays, MRI, CT scan); treatment planning which may include surgical intervention (open fracture reduction and internal fixation), wound care, pain management (analgesics, NSAIDs), immobilization (casts or splints), physical therapy, and management of any associated complications.

IMPORTANT Related codes include other S52.332 codes specifying different types of fractures and healing statuses (e.g., S52.332M for open fracture type I or II with nonunion, S52.332P for closed fracture with malunion).Additional codes may be necessary to specify the cause of the injury (from Chapter 20, External causes of morbidity) and any retained foreign body (Z18.-).

In simple words: This code is for a follow-up visit for a broken left forearm bone (radius) that didn't heal properly after a previous injury. The break was a diagonal break that went through the skin and is a serious type of break (types IIIA, IIIB, or IIIC).This visit is because the bone hasn't healed yet (nonunion).

This code signifies a subsequent encounter for a displaced oblique fracture of the left radius shaft.The fracture is classified as an open fracture (type IIIA, IIIB, or IIIC according to the Gustilo classification), characterized by a break line running diagonally across the radius's central portion.This specific code applies when the fracture has failed to unite (nonunion) after a previous encounter.The Gustilo classification indicates varying degrees of injury, including potential radial head dislocation, significant soft tissue damage, multiple fragments, periosteal stripping, and damage to nearby nerves and vessels, often resulting from high-energy trauma.

Example 1: A patient presents for a follow-up visit three months after an initial treatment for a type IIIB open fracture of the left radius. The fracture shows no signs of healing (nonunion).The physician assesses the patient, orders additional imaging, and discusses surgical options., A patient involved in a high-speed motor vehicle accident sustained an open, type IIIA fracture of the left radius with significant soft tissue damage. After initial surgery and a period of immobilization, the patient returns for evaluation. Radiographic findings reveal a nonunion, and the physician recommends revision surgery., A patient with a history of diabetes and poor vascularity presents for a follow-up visit after sustaining an open fracture of the left radius (type IIIC).Despite multiple surgical interventions, healing has not occurred. The physician consults with a specialist to consider bone grafting and advanced treatment modalities.

Detailed documentation is required, including the initial injury mechanism, initial treatment provided, imaging reports (X-rays, CT scans, MRI) showing the fracture, documentation of previous surgical interventions, evidence of nonunion (radiographic images), and the physician's assessment of the patient's condition and treatment plan.

** The Gustilo classification (types IIIA, IIIB, IIIC) is crucial for accurate coding.Understanding the nuances of nonunion versus malunion is essential for selecting the appropriate code from the S52.332 series.Always refer to the latest ICD-10-CM coding guidelines for the most up-to-date information.

  • Payment Status: Active
  • Modifier TC rule: TC modifiers would likely not apply to this diagnosis code, as it represents a diagnosis, not a procedure.
  • Specialties:Orthopedic Surgery, Trauma Surgery
  • Place of Service:Office, Hospital Inpatient, Hospital Outpatient, Ambulatory Surgical Center
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