The ICD-10 code for a left humerus fracture (specifically an unspecified fracture of the upper end) in a subsequent encounter with routine healing is S42.202D.
The ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) system provides highly specific codes to classify diagnoses and health conditions. For fractures, these codes specify the bone, location, laterality (left or right), and the nature of the encounter (initial, subsequent, or sequela).
Understanding S42.202D: Left Humerus Fracture, Subsequent Encounter
The code S42.202D is specifically used when documenting an unspecified fracture of the upper end of the left humerus during a subsequent encounter where the fracture is healing routinely. Each character or set of characters within the code provides precise information:
- S42: Indicates a fracture of the humerus.
- S42.2: Pinpoints the fracture to the upper end of the humerus.
- S42.20: Further specifies an unspecified fracture of the upper end of the humerus, meaning the exact type of fracture (e.g., transverse, oblique, comminuted) is not specified.
- S42.202: Identifies the fracture as occurring on the left side.
- D: This 7th character is crucial, signifying a subsequent encounter for fracture with routine healing. This means the patient is receiving follow-up care for the fracture, and the healing process is progressing as expected.
ICD-10-CM Code Breakdown
Below is a detailed breakdown of the components of this specific ICD-10-CM diagnosis code:
| Component | Description |
|---|---|
| Code | S42.202D |
| General Category | Fracture of humerus and scapula |
| Specific Type | Unspecified fracture of upper end of humerus |
| Laterality | Left side |
| Encounter Type | Subsequent encounter for fracture with routine healing |
Practical Application and Context
This code would be applied in various healthcare settings, such as:
- Follow-up Appointments: When a patient returns for a check-up after an initial injury, and the medical documentation indicates that the left humerus fracture is healing without complications.
- Rehabilitation Sessions: During physical therapy or occupational therapy sessions for a left humerus fracture where the focus is on recovery and the healing is progressing normally.
- Cast Changes/Removal: For visits related to the ongoing management of the fracture, like changing a cast or removing an external fixation, provided routine healing is observed.
It is vital for healthcare providers to select the correct 7th character based on the specific encounter. Other common 7th characters include 'A' for initial encounter, 'G' for subsequent encounter with delayed healing, 'K' for subsequent encounter with nonunion, 'P' for subsequent encounter with malunion, and 'S' for sequela (complications or conditions arising as a direct result of the fracture).
For more comprehensive information on ICD-10-CM coding, including details on S42.202D, refer to official coding resources such as the ICD-10-CM Diagnosis Code S42.202D entry.
[[ICD-10 Coding]]
