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ICD-10 Guide
ICD-10 CodesS22.022

S22.022

Billable

Unstable burst fracture of second thoracic vertebra

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/23/2025

Code Description

ICD-10 S22.022 is a billable code used to indicate a diagnosis of unstable burst fracture of second thoracic vertebra.

Key Diagnostic Point:

An unstable burst fracture of the second thoracic vertebra (T2) is a severe spinal injury characterized by the vertebra's failure due to high-energy trauma, often resulting in the vertebra shattering into multiple fragments. This type of fracture can lead to spinal cord injury, neurological deficits, and significant instability of the thoracic spine. Patients typically present with acute back pain, possible neurological symptoms such as weakness or sensory loss, and may have associated injuries such as rib fractures, pneumothorax, or hemothorax due to the proximity of the thoracic cavity. The management of an unstable burst fracture often requires surgical intervention, such as decompression and stabilization, to prevent further neurological compromise and to restore spinal alignment. The complexity of this injury necessitates thorough documentation of the mechanism of injury, associated injuries, and the treatment plan, as these factors significantly influence patient outcomes and coding accuracy.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Requires detailed documentation of the mechanism of injury.
  • Associated injuries (e.g., rib fractures, pneumothorax) complicate coding.
  • Potential for neurological involvement necessitates careful assessment.
  • Surgical interventions may vary, impacting coding specificity.

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury.
  • Failure to document associated injuries.
  • Misclassification of fracture stability.
  • Lack of clarity in surgical intervention details.

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative reports, imaging studies, and pre/post-operative assessments.

Common Clinical Scenarios

Surgical repair of unstable fractures, management of complications like infections.

Billing Considerations

Ensure clarity in the surgical approach and any hardware used.

Trauma Surgery

Documentation Requirements

Comprehensive trauma assessments, including mechanism of injury and associated injuries.

Common Clinical Scenarios

Management of polytrauma patients with thoracic injuries.

Billing Considerations

Document all injuries and interventions to support coding.

Coding Guidelines

Inclusion Criteria

Use S22.022 When
  • Follow official ICD
  • CM guidelines for coding fractures, including specificity for unstable fractures and associated injuries
  • Ensure to document the mechanism of injury and any neurological assessments

Exclusion Criteria

Do NOT use S22.022 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

22612CPT Code

Posterior spinal fusion

Clinical Scenario

Used in surgical management of unstable burst fractures.

Documentation Requirements

Operative report detailing the procedure and any hardware used.

Specialty Considerations

Orthopedic surgeons must document the rationale for surgical intervention.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of complex injuries like unstable burst fractures, improving the accuracy of patient records and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of complex injuries like unstable burst fractures, improving the accuracy of patient records and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

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 is the difference between stable and unstable burst fractures?

Stable burst fractures do not compromise spinal stability or the spinal canal, while unstable burst fractures involve significant displacement of fragments and potential neurological injury.