Nondisplaced fracture of body of scapula, unspecified shoulder
ICD-10 S42.116 is a billable code used to indicate a diagnosis of nondisplaced fracture of body of scapula, unspecified shoulder.
A nondisplaced fracture of the body of the scapula is characterized by a break in the bone that does not result in the separation of the bone fragments. This type of fracture typically occurs due to direct trauma, such as a fall or a sports-related injury. The scapula, or shoulder blade, plays a crucial role in shoulder stability and mobility, and fractures in this area can lead to pain, swelling, and limited range of motion. Patients may present with shoulder pain, tenderness, and difficulty lifting the arm. Diagnosis is usually confirmed through imaging studies, such as X-rays or CT scans, which can help differentiate between displaced and nondisplaced fractures. Treatment often involves conservative management, including rest, ice, and physical therapy, although surgical intervention may be necessary in cases of associated injuries or if conservative measures fail. Understanding the implications of a scapular fracture is essential for effective rehabilitation and recovery, as it can impact shoulder function and overall mobility.
Detailed operative reports, imaging studies, and post-operative notes are essential for accurate coding.
Fractures resulting from falls, sports injuries, or motor vehicle accidents.
Documentation must clearly indicate the fracture type and any surgical interventions performed.
Comprehensive assessments of functional limitations and rehabilitation progress notes.
Patients undergoing rehabilitation post-fracture for strength and mobility.
Focus on documenting the impact of the fracture on daily activities and rehabilitation goals.
Used when assessing shoulder injuries in conjunction with a scapular fracture.
Operative reports and imaging studies must be included.
Orthopedic surgeons should document the rationale for arthroscopy.
A displaced fracture involves a break in the bone where the ends are not aligned, while a nondisplaced fracture means the bone cracks but maintains its proper alignment.
