ICD-10-CM Code S02.109S

Fracture of base of skull, unspecified side, sequela

Version 2020 Billable Code POA Exempt

Valid for Submission

S02.109S is a billable code used to specify a medical diagnosis of fracture of base of skull, unspecified side, sequela. The code is valid for the year 2020 for the submission of HIPAA-covered transactions. The ICD-10-CM code S02.109S 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 cerebral laceration and/or contusion, 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, etc The code is exempt from present on admission (POA) reporting for inpatient admissions to general acute care hospitals.

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

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 cerebral laceration AND/OR contusion
  • 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 skull fracture with cerebral laceration AND/OR contusion
  • 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 injury
  • Open skull fracture without intracranial injury

Present on Admission (POA)

S02.109S is exempt from POA reporting - The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement. Review other POA exempt codes here .

CMS POA Indicator Options and Definitions
POA Indicator CodePOA Reason for CodeCMS will pay the CC/MCC DRG?
YDiagnosis was present at time of inpatient admission.YES
NDiagnosis was not present at time of inpatient admission.NO
UDocumentation insufficient to determine if the condition was present at the time of inpatient admission.NO
WClinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission.YES
1Unreported/Not used - Exempt from POA reporting. NO

Replacement Code

S02109S replaces the following previously assigned ICD-10 code(s):

  • S02.10XS - Unspecified fracture of base of skull, sequela

Convert S02.109S to ICD-9

  • 905.0 - Late effec skull/face fx (Approximate Flag)

Code Classification

  • Injury, poisoning and certain other consequences of external causes (S00–T98)
    • Injuries to the head (S00-S09)
      • Fracture of skull and facial bones (S02)

Code History

  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020

Information for Patients


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.


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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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