Other fracture of occiput, unspecified side
ICD-10 S02.118 is a billable code used to indicate a diagnosis of other fracture of occiput, unspecified side.
The code S02.118 refers to fractures of the occipital bone, which is located at the back of the skull. These fractures can occur due to various mechanisms of injury, including blunt trauma from falls, motor vehicle accidents, or sports injuries. The occipital bone protects the brain and supports the skull's structure, making fractures in this area potentially serious. Symptoms may include headache, neck pain, and neurological deficits depending on the severity and location of the fracture. Diagnosis typically involves imaging studies such as CT scans or X-rays to confirm the fracture and assess for any associated injuries. Management may range from conservative treatment, such as pain management and observation, to surgical intervention in cases of significant displacement or associated complications. Complications can include intracranial hemorrhage, nerve damage, and chronic pain syndromes. Accurate coding is essential for appropriate treatment and reimbursement, necessitating thorough documentation of the injury mechanism, clinical findings, and treatment provided.
Documentation must include a detailed account of the mechanism of injury, initial assessment findings, and any imaging results.
Patients presenting with head trauma after falls or accidents, requiring immediate evaluation and imaging.
Ensure that all neurological assessments are documented, as they are critical for determining the severity of the injury.
Operative reports must detail the surgical approach, findings, and any repairs made to the occipital bone.
Surgical intervention for displaced fractures or those associated with intracranial injuries.
Document any pre-existing conditions that may affect surgical outcomes or recovery.
Used when surgical intervention is required for an occipital fracture with associated brain injury.
Operative report must detail the procedure, findings, and any complications.
Neurosurgical documentation must include neurological assessments pre- and post-operatively.
Specifying the side of the occipital fracture is crucial for determining the potential impact on neurological function and guiding treatment. Unspecified codes may lead to challenges in treatment planning and reimbursement.
