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ICD-10 Guide
ICD-10 CodesS02.81

S02.81

Billable

Fracture of other specified skull and facial bones, right side

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

Code Description

ICD-10 S02.81 is a billable code used to indicate a diagnosis of fracture of other specified skull and facial bones, right side.

Key Diagnostic Point:

The S02.81 code is used to classify fractures of the skull and facial bones that are not specifically categorized elsewhere in the ICD-10 coding system. This code specifically pertains to fractures occurring on the right side of the skull or facial bones, which may include the zygomatic bone, maxilla, nasal bones, or other unspecified bones in the craniofacial region. Such fractures can result from various mechanisms of injury, including blunt trauma from falls, motor vehicle accidents, sports injuries, or assaults. Clinical presentation may include localized pain, swelling, bruising, and potential neurological symptoms if the fracture involves the cranial vault. Diagnosis typically involves imaging studies such as X-rays or CT scans to confirm the fracture and assess for associated injuries. Management may range from conservative treatment with pain management and observation to surgical intervention for more complex fractures requiring stabilization or reconstruction.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in fracture types and locations
  • Need for precise documentation of injury mechanism
  • Potential for associated injuries requiring additional codes
  • Differentiation from similar codes for accurate coding

Audit Risk Factors

  • Inadequate documentation of the specific fracture site
  • Failure to document the mechanism of injury
  • Incorrect coding of associated injuries
  • Misinterpretation of imaging results

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Documentation must include details of the mechanism of injury, clinical findings, and imaging results.

Common Clinical Scenarios

Trauma cases presenting with facial injuries from falls or accidents.

Billing Considerations

Ensure that all relevant injuries are documented to avoid undercoding.

Surgery

Documentation Requirements

Operative reports must detail the surgical approach, findings, and any reconstruction performed.

Common Clinical Scenarios

Surgical management of complex facial fractures requiring fixation or reconstruction.

Billing Considerations

Accurate coding of surgical procedures in conjunction with fracture codes is essential.

Coding Guidelines

Inclusion Criteria

Use S02.81 When
  • Follow the official ICD
  • CM coding guidelines, ensuring specificity in documentation regarding the fracture site and mechanism of injury
  • Use additional codes for associated injuries as necessary

Exclusion Criteria

Do NOT use S02.81 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

21310CPT Code

Closed treatment of zygomatic arch fracture

Clinical Scenario

Used when a zygomatic arch fracture is treated without surgical incision.

Documentation Requirements

Document the type of fracture and treatment provided.

Specialty Considerations

Ensure that the fracture type aligns with the procedure performed.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding fractures, which aids in better tracking of injury patterns and outcomes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding fractures, which aids in better tracking of injury patterns and outcomes.

Reimbursement & Billing Impact

reimbursement process.

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

What documentation is required for S02.81?

Documentation must include the specific fracture site, mechanism of injury, imaging results, and any associated injuries or treatments.