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v1.0.0
ICD-10 Guide
ICD-10 CodesS02.119

S02.119

Billable

Unspecified fracture of occiput

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 S02.119 is a billable code used to indicate a diagnosis of unspecified fracture of occiput.

Key Diagnostic Point:

An unspecified fracture of the occiput refers to a break in the bone structure at the back of the skull, which can occur due to various mechanisms of injury, including blunt force trauma, falls, or vehicular accidents. The occipital bone is critical for protecting the brain and supporting the skull's structure. Symptoms may include headache, neck pain, dizziness, 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, including rest and pain management, to surgical intervention in cases of significant displacement or associated complications. Given the potential for serious complications, including intracranial hemorrhage or neurological impairment, timely and accurate diagnosis and treatment are essential.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and symptoms
  • Need for imaging studies for accurate diagnosis
  • Potential for associated injuries requiring additional coding
  • Differentiation from other skull fractures

Audit Risk Factors

  • Inadequate documentation of mechanism of injury
  • Failure to specify the type of fracture
  • Misclassification of fracture severity
  • Lack of imaging documentation

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Documentation must include details of the mechanism of injury, initial assessment findings, and any imaging results.

Common Clinical Scenarios

Patients presenting with head trauma from falls or accidents, requiring immediate evaluation and imaging.

Billing Considerations

Ensure that all relevant symptoms and potential complications are documented to support the diagnosis.

Surgery

Documentation Requirements

Operative reports must detail the surgical approach, findings, and any repairs made to the occipital bone.

Common Clinical Scenarios

Surgical intervention for displaced fractures or those associated with intracranial injuries.

Billing Considerations

Accurate coding requires clear documentation of the surgical procedure and any complications encountered.

Coding Guidelines

Inclusion Criteria

Use S02.119 When
  • Follow official ICD
  • CM coding guidelines, ensuring that the code is used only when the fracture is confirmed and unspecified
  • Document the mechanism of injury and any associated conditions

Exclusion Criteria

Do NOT use S02.119 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

64718CPT Code

Decompression of cranial cavity

Clinical Scenario

Used in cases where there is significant displacement or intracranial pressure.

Documentation Requirements

Operative report must detail the procedure and findings.

Specialty Considerations

Neurosurgery documentation must include indications for surgery and any complications.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of fractures, but the unspecified nature of S02.119 can lead to challenges in documentation and coding accuracy.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of fractures, but the unspecified nature of S02.119 can lead to challenges in documentation and coding accuracy.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of fractures, but the unspecified nature of S02.119 can lead to challenges in documentation and coding accuracy.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

When should I use S02.119?

Use S02.119 when there is a confirmed fracture of the occiput that is unspecified, and ensure that documentation supports the diagnosis and mechanism of injury.