2025 ICD-10-CM Diagnosis Code S02

Specific Coding Applicable to Fracture of skull and facial bones

Non-specific codes like S02 require more digits to indicate the appropriate level of specificity. Consider using any of the following ICD-10-CM codes with a higher level of specificity when coding for fracture of skull and facial bones:

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).

Patient Education

Facial Injuries and Disorders

Face injuries and disorders can cause pain and affect how you look. In severe cases, they can affect sight, speech, breathing and your ability to swallow. Fractures (broken bones), especially in the bones of your nose, cheekbone and jaw, are common facial injuries.

Certain diseases also lead to facial disorders. For example, nerve diseases like trigeminal neuralgia or Bell's palsy sometimes cause facial pain, spasms and trouble with eye or facial movement. Birth defects can also affect the face. They can cause underdeveloped or unusually prominent facial features or a lack of facial expression. Cleft lip and palate are a common facial birth defect.

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Fractures

What is a fracture?

A fracture is a break in a bone. Fractures are usually caused by injuries. Since they can sometimes be serious, it's important to get medical care right away if you think you have a fracture.

What are the different types of fractures?

There are different ways to describe fractures. For example, there are different types of fractures based on:

• Whether the bone is partially or completely broken.
• Whether the bone breaks through the skin; if it does, it's called an open (or compound) fracture. If not, it's a closed fracture.
• The direction or shape of the break, for example if it's in a line across the bone or if it has some kind of pattern.
• The cause of the break. For example, a stress fracture is a small break in a bone that is often caused by overuse.
• Which bone is broken, for example facial fractures include nose and jaw fractures.

What causes fractures?

Fractures commonly happen because of car accidents, falls, or sports injuries. Overuse and repetitive motions can also cause fractures.

Low bone density and osteoporosis are conditions which cause weakening of your bones. Having one of these conditions makes you much more likely to break a bone.

What are the symptoms of a fracture?

The symptoms of a fracture can vary, depending on which bone you broke. But they may include:

• Intense pain
• Deformity, for example a limb that looks out of place
• Swelling, bruising, or tenderness around the injury
• Trouble moving the injured part

If you think that you may have broken a bone, get medical care right away.

How are fractures diagnosed?

To find out if you have a fracture, your health provider will do a physical exam and ask about your injury. They will also likely order an x-ray or other imaging test to see if your bone is broken.

What are the treatments for fractures?

The most common treatment for a fracture is for you to wear a cast or a splint. This will keep your bone from moving while it heals. How long you need to wear it will depend on the type of fracture and which bone is affected. But it's often for several weeks. Your provider will let you when you can get it off.

In some cases, you may need surgery to put in plates, pins, or screws to keep the bone in place.

Can fractures be prevented?

There are steps you can take to lower your risk of fractures:

• Keeping your bones strong by:
  • Getting enough calcium and vitamin D in your diet
  • Getting regular physical activity, including weight bearing exercises such as walking, tennis, and dancing
  • Getting treatment for low bone density or osteoporosis (if needed)
• Wearing protective equipment when you do sports
• Preventing falls by:
  • Getting rid of any tripping hazards in your home
  • Being careful when walking on wet or icy surfaces
  • Choosing the right footwear

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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

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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.