Unspecified fracture of upper end of humerus
ICD-10 S42.20 is a billable code used to indicate a diagnosis of unspecified fracture of upper end of humerus.
The unspecified fracture of the upper end of the humerus refers to a break in the proximal region of the humerus bone, which is located near the shoulder joint. This type of fracture can occur due to various mechanisms, including falls, direct trauma, or sports injuries. Patients may present with shoulder pain, swelling, and limited range of motion. The diagnosis is typically confirmed through imaging studies such as X-rays or MRI, which help to visualize the fracture and assess any associated injuries to the surrounding soft tissues, including the rotator cuff. Treatment options may vary based on the severity of the fracture and can include conservative management with physical therapy and immobilization or surgical intervention to stabilize the fracture. Surgical options may involve the use of plates, screws, or intramedullary nails. The prognosis for recovery is generally good, but it can be complicated by factors such as age, comorbidities, and the presence of associated injuries.
Detailed operative reports, imaging studies, and follow-up notes.
Fractures resulting from falls, sports injuries, or trauma requiring surgical intervention.
Accurate documentation of fracture type, treatment plan, and any complications is crucial for proper coding.
Initial evaluation notes, progress notes, and discharge summaries.
Rehabilitation following surgical repair of humeral fractures or conservative management of fractures.
Documentation should reflect the patient's functional status and response to therapy.
Used in cases where a rotator cuff injury is present alongside a humeral fracture.
Operative report detailing the procedure and findings.
Orthopedic surgeons should ensure that the documentation clearly links the procedure to the diagnosis.
S42.20 should be used when the documentation does not specify the exact type or location of the fracture. If more specific information is available, it is advisable to use those codes to ensure accurate billing and reporting.
