Fracture of base of skull, unspecified side
ICD-10 S02.109 is a billable code used to indicate a diagnosis of fracture of base of skull, unspecified side.
A fracture of the base of the skull is a serious injury that can occur due to high-impact trauma, such as motor vehicle accidents, falls from significant heights, or violent assaults. The base of the skull is the area that supports the brain and houses critical structures such as the brainstem and cranial nerves. Fractures in this area can lead to complications such as cerebrospinal fluid leaks, cranial nerve damage, and intracranial hemorrhage. Symptoms may include headache, confusion, loss of consciousness, and neurological deficits. Diagnosis typically involves imaging studies such as CT scans or MRIs to assess the extent of the fracture and any associated injuries. Management may require surgical intervention, especially if there is significant displacement or associated complications. The prognosis depends on the severity of the fracture and the presence of any additional injuries.
Complete documentation of the patient's condition upon arrival, including vital signs, neurological status, and mechanism of injury.
Patients presenting after a fall or motor vehicle accident with altered mental status.
Ensure that all relevant imaging studies are documented and that the mechanism of injury is clearly stated.
Detailed operative reports that outline the surgical approach, findings, and any complications encountered during the procedure.
Surgical intervention for displaced fractures or associated intracranial injuries.
Document any pre-existing conditions that may affect surgical outcomes.
Used in cases of significant intracranial pressure or hematoma associated with skull fractures.
Operative report detailing the procedure and indications for surgery.
Neurosurgery documentation must include preoperative imaging and postoperative outcomes.
Document the mechanism of injury, imaging results, neurological status, and any associated injuries or complications to ensure accurate coding.
