2022 ICD-10-CM Code S02.40D

Maxillary fracture, left side

Version 2021

Not Valid for Submission

ICD-10:S02.40D
Short Description:Maxillary fracture, left side
Long Description:Maxillary fracture, left side

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)

S02.40D is a non-specific and non-billable diagnosis code code, consider using a code with a higher level of specificity for a diagnosis of maxillary fracture, left side. The code is not specific and is NOT valid for the year 2022 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 S02.40D might also be used to specify conditions or terms like closed fracture of left maxilla, fracture of upper jaw, closed or open fracture of left maxilla.

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 Maxillary fracture, left side

Non-specific codes like S02.40D 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 maxillary fracture, left side:

  • BILLABLE CODE - Use S02.40DA for initial encounter for closed fracture
  • BILLABLE CODE - Use S02.40DB for initial encounter for open fracture
  • BILLABLE CODE - Use S02.40DD for subsequent encounter for fracture with routine healing
  • BILLABLE CODE - Use S02.40DG for subsequent encounter for fracture with delayed healing
  • BILLABLE CODE - Use S02.40DK for subsequent encounter for fracture with nonunion
  • BILLABLE CODE - Use S02.40DS for sequela

Index to Diseases and Injuries

The Index to Diseases and Injuries is an alphabetical listing of medical terms, with each term mapped to one or more ICD-10 code(s). The following references for the code S02.40D are found in the index:

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


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.


[Learn More in MedlinePlus]

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

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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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