Unspecified nondisplaced fracture of surgical neck of left humerus
ICD-10 S42.215 is a billable code used to indicate a diagnosis of unspecified nondisplaced fracture of surgical neck of left humerus.
The unspecified nondisplaced fracture of the surgical neck of the left humerus refers to a break in the bone that occurs at the surgical neck, which is a common site for fractures in the humerus, particularly in older adults or those with osteoporosis. This type of fracture is characterized by the absence of displacement, meaning the bone fragments remain in their normal anatomical position. Patients typically present with shoulder pain, swelling, and limited range of motion. Diagnosis is usually confirmed through imaging studies such as X-rays, which can reveal the fracture without displacement. Treatment often involves conservative management, including immobilization with a sling, pain management, and physical therapy to restore function. Surgical intervention may be considered if there are complications or if conservative treatment fails. Understanding the nuances of this fracture type is crucial for accurate coding and appropriate management.
Detailed operative notes if surgery is performed, imaging reports, and follow-up assessments.
Fractures resulting from falls, sports injuries, or osteoporosis-related incidents.
Ensure clear documentation of fracture type and treatment plan to support coding.
Progress notes detailing rehabilitation exercises, patient response, and functional outcomes.
Post-fracture rehabilitation focusing on restoring range of motion and strength.
Documenting the initial assessment and ongoing treatment plans is crucial for accurate coding.
Used when a rotator cuff injury is present alongside the fracture.
Operative notes detailing the procedure and findings.
Orthopedic surgeons must document the necessity for surgery based on the fracture type.
A nondisplaced fracture means the bone cracks but maintains its proper alignment, while a displaced fracture involves the bone fragments moving out of their normal position.
