Unspecified displaced fracture of surgical neck of unspecified humerus
ICD-10 S42.213 is a billable code used to indicate a diagnosis of unspecified displaced fracture of surgical neck of unspecified humerus.
The unspecified displaced fracture of the surgical neck of the humerus is a common injury, particularly among older adults and individuals involved in high-impact sports. This type of fracture occurs at the surgical neck, which is located just below the head of the humerus, and is characterized by a break that has resulted in the bone fragments being misaligned. Symptoms typically include severe pain, swelling, and limited range of motion in the shoulder. Diagnosis is usually confirmed through physical examination and imaging studies such as X-rays or MRI. Treatment options vary based on the severity of the fracture and may include conservative management with immobilization, physical therapy, or surgical intervention to realign the bone fragments. Surgical options may involve the use of plates, screws, or intramedullary nails to stabilize the fracture. Rehabilitation is crucial for restoring function and strength to the shoulder joint following treatment. The complexity of managing this condition is heightened by the potential for associated injuries, such as rotator cuff tears or shoulder dislocations, which can complicate the clinical picture and treatment approach.
Detailed operative reports, imaging studies, and post-operative notes are essential for accurate coding.
Fractures resulting from falls, sports injuries, or trauma requiring surgical intervention.
Documentation must clearly indicate the type of fracture, treatment provided, and any complications encountered.
Progress notes detailing rehabilitation goals, treatment modalities, and patient response to therapy.
Rehabilitation following surgical repair of humeral fractures or conservative management of shoulder injuries.
Therapy notes should correlate with the surgical or conservative treatment plan to ensure proper coding.
Used in cases where a rotator cuff injury is present alongside a humeral fracture.
Operative report detailing the procedure and findings.
Orthopedic surgeons must document the relationship between the fracture and any rotator cuff repairs.
S42.213 refers to an unspecified displaced fracture, while S42.211 is for a non-displaced fracture. Accurate documentation is crucial to determine the correct code.
