2021 ICD-10-CM Code S02.109

Fracture of base of skull, unspecified side

Version 2021

Not Valid for Submission

S02.109 is a non-specific and non-billable diagnosis code code, consider using a code with a higher level of specificity for a diagnosis of fracture of base of skull, unspecified side. The code is not specific and is NOT valid for the year 2021 for the submission of HIPAA-covered transactions. Category or Header define the heading of a category of codes that may be further subdivided by the use of 4th, 5th, 6th or 7th characters.

The ICD-10-CM code S02.109 might also be used to specify conditions or terms like cerebral laceration and contusion, closed fracture of base of skull, closed fracture of base of skull with concussion, closed fracture of base of skull with intracranial hemorrhage, closed fracture of base of skull with intracranial injury , closed fracture of base of skull with intracranial injury, with no loss of consciousness, etc.

Unspecified diagnosis codes like S02.109 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.

ICD-10:S02.109
Short Description:Fracture of base of skull, unspecified side
Long Description:Fracture of base of skull, unspecified side

Code 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).

Specific Coding for Fracture of base of skull, unspecified side

Non-specific codes like S02.109 require more digits to indicate the appropriate level of specificity. Consider using any of the following ICD-10 codes with a higher level of specificity when coding for fracture of base of skull, unspecified side:

  • BILLABLE CODE - Use S02.109A for initial encounter for closed fracture
  • BILLABLE CODE - Use S02.109B for initial encounter for open fracture
  • BILLABLE CODE - Use S02.109D for subsequent encounter for fracture with routine healing
  • BILLABLE CODE - Use S02.109G for subsequent encounter for fracture with delayed healing
  • BILLABLE CODE - Use S02.109K for subsequent encounter for fracture with nonunion
  • BILLABLE CODE - Use S02.109S for sequela

Approximate Synonyms

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

Information for Patients


Fractures

Also called: Broken bone

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

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

Also called: Cranial injuries, Skull fractures, Skull 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

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 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