2024 ICD-10-CM Diagnosis Code S02.91XA

Unspecified fracture of skull, initial encounter for closed fracture

ICD-10-CM Code:
S02.91XA
ICD-10 Code for:
Unsp fracture of skull, init encntr for closed fracture
Is Billable?
Yes - Valid for Submission
Chronic Condition Indicator: [1]
Not chronic
Code Navigator:

Code Classification

  • Injury, poisoning and certain other consequences of external causes
    (S00–T88)
    • Injuries to the head
      (S00-S09)
      • Fracture of skull and facial bones
        (S02)

S02.91XA is a billable diagnosis code used to specify a medical diagnosis of unspecified fracture of skull, initial encounter for closed fracture. The code is valid during the current fiscal year for the submission of HIPAA-covered transactions from October 01, 2023 through September 30, 2024.

S02.91XA is an initial encounter code, includes a 7th character and should be used while the patient is receiving active treatment for a condition like unspecified fracture of skull for closed fracture. According to ICD-10-CM Guidelines an "initial encounter" doesn't necessarily means "initial visit". The 7th character should be used when the patient is undergoing active treatment regardless if new or different providers saw the patient over the course of a treatment. The appropriate 7th character codes should also be used even if the patient delayed seeking treatment for a condition.

Unspecified diagnosis codes like S02.91XA are acceptable when clinical information is unknown or not available about a particular condition. Although a more specific code is preferable, unspecified codes should be used when such codes most accurately reflect what is known about a patient's condition. Specific diagnosis codes should not be used if not supported by the patient's medical record.

Approximate Synonyms

The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:

  • Closed fracture of skull
  • Closed fracture of skull with cerebral contusion
  • Closed fracture of skull with cerebral laceration
  • Closed skull fracture with intracranial hemorrhage
  • Closed skull fracture with intracranial injury
  • Closed skull fracture with intracranial injury
  • Closed skull fracture with intracranial injury
  • Fracture of multiple bones of face
  • Fracture of multiple bones of face
  • Fracture of skull
  • Fracture of skull and facial bones
  • Fractures involving head with neck
  • Multiple closed fractures of skull AND/OR face without intracranial injury
  • Multiple fractures involving skull and facial bones
  • Multiple fractures of skull
  • Multiple fractures of skull
  • Multiple fractures of skull
  • Multiple open fractures of skull
  • Open fracture of skull
  • Open fracture of skull with cerebral contusion
  • Open fracture of skull with cerebral laceration
  • Open skull fracture with intracranial hemorrhage
  • Open skull fracture with intracranial injury

Clinical Classification

Coding Guidelines

The principles of multiple coding of injuries should be followed in coding fractures. Fractures of specified sites are coded individually by site nd the level of detail furnished by medical record content.

A fracture not indicated as open or closed should be coded to closed. A fracture not indicated whether displaced or not displaced should be coded to displaced.

Initial vs. Subsequent Encounter for Fractures

Traumatic fractures are coded using the appropriate 7th character for initial encounter (A, B, C) for each encounter where the patient is receiving active treatment for the fracture. The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.

Fractures are coded using the appropriate 7th character for subsequent care for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase.

Care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes.

Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7th character for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R).

Malunion/nonunion: The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.

The open fracture designations in the assignment of the 7th character for fractures of the forearm, femur and lower leg, including ankle are based on the Gustilo open fracture classification. When the Gustilo classification type is not specified for an open fracture, the 7th character for open fracture type I or II should be assigned (B, E, H, M, Q).

Convert S02.91XA to ICD-9-CM

  • ICD-9-CM Code: 803.00 - Close skull fracture NEC
    Approximate Flag - The approximate mapping means there is not an exact match between the ICD-10 and ICD-9 codes and the mapped code is not a precise representation of the original code.

Patient Education


Fractures

A fracture is a break, usually in a bone. If the broken bone punctures the skin, it is called an open or compound fracture. Fractures commonly happen because of car accidents, falls, or sports injuries. Other causes are low bone density and osteoporosis, which cause weakening of the bones. Overuse can cause stress fractures, which are very small cracks in the bone.

Symptoms of a fracture are:

  • Intense pain
  • Deformity - the limb looks out of place
  • Swelling, bruising, or tenderness around the injury
  • Numbness and tingling
  • Problems moving a limb

You need to get medical care right away for any fracture. An x-ray can tell if your bone is broken. You may need to wear a cast or splint. Sometimes you need surgery to put in plates, pins or screws to keep the bone in place.


[Learn More in MedlinePlus]

Head Injuries

Chances are you've bumped your head before. Often, the injury is minor because your skull is hard and it protects your brain. But other head injuries can be more severe, such as a skull fracture, concussion, or traumatic brain injury.

Head injuries can be open or closed. A closed injury does not break through the skull. With an open, or penetrating, injury, an object pierces the skull and enters the brain. Closed injuries are not always less severe than open injuries.

Some common causes of head injuries are falls, motor vehicle accidents, violence, and sports injuries.

It is important to know the warning signs of a moderate or severe head injury. Get help immediately if the injured person has:

  • A headache that gets worse or does not go away
  • Repeated vomiting or nausea
  • Convulsions or seizures
  • An inability to wake up
  • Dilated (enlarged) pupil in one or both eyes
  • Slurred speech
  • Weakness or numbness in the arms or legs
  • Loss of coordination
  • Increased confusion, restlessness, or agitation

Doctors use a neurologic exam and imaging tests to make a diagnosis. Treatment depends on the type of injury and how severe it is.

NIH: National Institute of Neurological Disorders and Stroke


[Learn More in MedlinePlus]

Code History

  • FY 2024 - No Change, effective from 10/1/2023 through 9/30/2024
  • FY 2023 - No Change, effective from 10/1/2022 through 9/30/2023
  • FY 2022 - No Change, effective from 10/1/2021 through 9/30/2022
  • FY 2021 - No Change, effective from 10/1/2020 through 9/30/2021
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016. This was the first year ICD-10-CM was implemented into the HIPAA code set.

Footnotes

[1] Not chronic - A diagnosis code that does not fit the criteria for chronic condition (duration, ongoing medical treatment, and limitations) is considered not chronic. Some codes designated as not chronic are acute conditions. Other diagnosis codes that indicate a possible chronic condition, but for which the duration of the illness is not specified in the code description (i.e., we do not know the condition has lasted 12 months or longer) also are considered not chronic.