2021 ICD-10-CM Code S02.109A
Fracture of base of skull, unspecified side, initial encounter for closed fracture
Valid for Submission
S02.109A is a billable diagnosis code used to specify a medical diagnosis of fracture of base of skull, unspecified side, initial encounter for closed fracture. The code S02.109A is valid during the fiscal year 2021 from October 01, 2020 through September 30, 2021 for the submission of HIPAA-covered transactions.
The ICD-10-CM code S02.109A 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.
S02.109A is an initial encounter code, includes a 7th character and should be used while the patient is receiving active treatment for a condition like fracture of base of skull unspecified side 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 S02.109A 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.
The code S02.109A is linked to some Quality Measures as part of Medicare's Quality Payment Program (QPP). When this code is used as part of a patient's medical record the following Quality Measures might apply: Emergency Medicine: Emergency Department Utilization Of Ct For Minor Blunt Head Trauma For Patients Aged 2 Through 17 Years.
| ICD-10: | S02.109A |
| Short Description: | Fracture of base of skull, unspecified side, init |
| Long Description: | Fracture of base of skull, unspecified side, initial encounter for closed fracture |
Code Classification
Approximate Synonyms
The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:
- 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
- Closed fracture of base of skull with loss of consciousness
- Closed fracture of base of skull without intracranial injury
- Closed injury of head
- Closed skull fracture with intracranial hemorrhage
- Closed skull fracture with intracranial injury
- Closed skull fracture without intracranial injury
- Fracture of base of skull
- Fracture of ethmoid sinus
- Open fracture of base of skull
- Open fracture of base of skull with cerebral laceration AND contusion
- Open fracture of base of skull with intracranial hemorrhage
- Open fracture of base of skull with intracranial injury
- Open fracture of base of skull with intracranial injury, with no loss of consciousness
- Open fracture of base of skull without intracranial injury
- Open skull fracture with intracranial hemorrhage
- Open skull fracture without intracranial injury
Replacement Code
S02109A replaces the following previously assigned ICD-10 code(s):
- S02.10XA - Unsp fracture of base of skull, init for clos fx
Convert S02.109A to ICD-9 Code
The General Equivalency Mapping (GEM) crosswalk indicates an approximate mapping between the ICD-10 code S02.109A its ICD-9 equivalent. The approximate mapping means there is not an exact match between the ICD-10 code and the ICD-9 code and the mapped code is not a precise representation of the original code.
- 801.00 - Clos skull base fracture (Approximate Flag)
Quality Payment Program Measures
When code S02.109A is part of the patient's diagnoses the following Quality Measures apply and affect reimbursement. The objective of Medicare's Quality Measures is to improve patient care by making it more: effective, safe, efficient, patient-centered and equitable.
| Quality Measure | Description | Quality Domain | Measure Type | High Priority | Submission Methods |
|---|---|---|---|---|---|
| Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 2 Through 17 Years | Percentage of emergency department visits for patients aged 2 through 17 years who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who are classified as low risk according to the Pediatric Emergency Care Applied Research Network (PECARN) prediction rules for traumatic brain injury. | Efficiency and Cost Reduction | Efficiency | YES | Claims, Registry |
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
- 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.
- Broken bone (Medical Encyclopedia)
- Closed reduction of a fractured bone (Medical Encyclopedia)
- Closed reduction of a fractured bone - aftercare (Medical Encyclopedia)
[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
- 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
- Head injury - first aid (Medical Encyclopedia)
- Skull fracture (Medical Encyclopedia)
[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