Fracture of base of skull, left side
ICD-10 S02.102 is a billable code used to indicate a diagnosis of fracture of base of skull, left side.
A fracture of the base of the skull on the left side is a serious injury that can result from high-impact trauma, such as motor vehicle accidents, falls from significant heights, or violent assaults. This type of fracture can lead to various complications, including cerebrospinal fluid leaks, cranial nerve damage, and intracranial hemorrhage. Clinically, patients may present with symptoms such as headache, confusion, loss of consciousness, or neurological deficits. Diagnosis typically involves imaging studies, primarily CT scans, which can reveal the extent and location of the fracture. Management may include observation, surgical intervention to repair the fracture or address complications, and supportive care. Given the potential for serious outcomes, prompt and accurate diagnosis and treatment are critical.
Documentation must include the mechanism of injury, initial assessment findings, and any neurological evaluations.
Trauma patients presenting with altered mental status after a fall or collision.
Ensure that all relevant imaging studies are documented and that any immediate interventions are noted.
Operative reports must detail the surgical approach, findings, and any repairs made to the skull base.
Patients requiring surgical intervention for skull base fractures with associated complications.
Document any intraoperative findings that may affect coding, such as the presence of cerebrospinal fluid leaks.
Used in cases of skull base fractures with significant intracranial pressure.
Operative report must detail the procedure and findings.
Neurosurgery documentation must include indications for surgery.
Common complications include cerebrospinal fluid leaks, cranial nerve injuries, and intracranial hemorrhage, which can lead to serious neurological deficits.
