2024 ICD-10-CM Diagnosis Code S02.109A

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
• Closed fracture of base of skull
• Closed fracture of base of skull
• Closed fracture of base of skull
• Closed fracture of base of skull
• Closed fracture of base of skull
• Closed fracture of base of skull with cerebral contusion
• Closed fracture of base of skull with cerebral laceration
• 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
• Closed fracture of base of skull with intracranial injury
• Closed fracture of base of skull with intracranial injury
• Closed fracture of base of skull with intracranial injury
• Closed fracture of base of skull with loss of consciousness
• 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
• Closed skull fracture with intracranial injury
• Closed skull fracture with intracranial injury
• Fracture of base of skull
• Fracture of bone of nasal sinus
• Fracture of ethmoid bone
• Fracture of ethmoid sinus
• Open fracture of base of skull
• Open fracture of base of skull
• Open fracture of base of skull
• Open fracture of base of skull
• 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
• Open fracture of base of skull with intracranial injury, with no loss of consciousness
• Open fracture of skull with cerebral contusion
• Open fracture of skull with cerebral laceration
• Open skull fracture with intracranial hemorrhage

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).

Code Edits

The Medicare Code Editor (MCE) detects and reports errors in the coding of claims data. The following ICD-10-CM Code Edits are applicable to this code:

• Unspecified codes - Unspecified codes exist in the ICD-10-CM classification for circumstances when documentation in the medical record does not provide the level of detail needed to support reporting a more specific code. However, in the inpatient setting, there should generally be very limited and rare circumstances for which the laterality (right, left, bilateral) of a condition is unable to be documented and reported. The following pages contain the list of unspecified ICD-10-CM diagnosis codes for which there is a more specific code to identify laterality (right, left, bilateral) within that code family.

Replacement Code

S02109A replaces the following previously assigned ICD-10-CM code(s):

• S02.10XA - Unsp fracture of base of skull, init for clos fx

Convert to ICD-9-CM Code

Source ICD-10-CM Code		Target ICD-9-CM Code
S02.109A		801.00 - Clos skull base fracture
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