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ICD-10 Guide
ICD-10 CodesS42.26

S42.26

Billable

Fracture of lesser tuberosity of humerus

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/24/2025

Code Description

ICD-10 S42.26 is a billable code used to indicate a diagnosis of fracture of lesser tuberosity of humerus.

Key Diagnostic Point:

The fracture of the lesser tuberosity of the humerus is a specific type of shoulder injury that typically occurs due to trauma, such as a fall or direct impact. This fracture is significant because it can affect the function of the rotator cuff, particularly the subscapularis muscle, which is responsible for internal rotation of the shoulder. Patients may present with shoulder pain, limited range of motion, and swelling. Diagnosis is usually confirmed through imaging studies, such as X-rays or MRI, which can reveal the fracture's location and any associated soft tissue injuries. Treatment may vary from conservative management, including physical therapy and pain management, to surgical intervention, particularly if there is significant displacement or involvement of the rotator cuff. Surgical options may include open reduction and internal fixation (ORIF) or arthroscopic repair, depending on the fracture's complexity and the patient's overall health. Rehabilitation is crucial for restoring shoulder function and preventing long-term complications.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires understanding of shoulder anatomy and biomechanics.
  • Differentiation from other humeral fractures can be challenging.
  • Potential for associated rotator cuff injuries complicates coding.
  • Documentation must specify the type and extent of the fracture.

Audit Risk Factors

  • Inadequate documentation of fracture type and location.
  • Failure to document associated injuries, such as rotator cuff tears.
  • Misuse of codes for surgical procedures related to the fracture.
  • Inconsistent coding across different healthcare providers.

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative reports, imaging results, and post-operative care notes.

Common Clinical Scenarios

Fractures resulting from falls, sports injuries, or accidents requiring surgical intervention.

Billing Considerations

Ensure documentation reflects the complexity of the fracture and any surgical repairs performed.

Physical Therapy

Documentation Requirements

Progress notes detailing range of motion, strength assessments, and rehabilitation goals.

Common Clinical Scenarios

Patients recovering from surgical repair of the lesser tuberosity fracture.

Billing Considerations

Document functional limitations and progress to support ongoing therapy needs.

Coding Guidelines

Inclusion Criteria

Use S42.26 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the fracture type, location, and any associated injuries
  • Include details about the mechanism of injury and treatment plan

Exclusion Criteria

Do NOT use S42.26 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

23470CPT Code

Arthroscopic repair of rotator cuff

Clinical Scenario

Used when a rotator cuff repair is performed alongside the fracture repair.

Documentation Requirements

Operative report detailing the procedure and findings.

Specialty Considerations

Orthopedic surgeons must document the extent of the rotator cuff injury.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of fractures, including the lesser tuberosity of the humerus, which enhances the ability to track treatment outcomes and resource utilization. This specificity aids in better patient management and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of fractures, including the lesser tuberosity of the humerus, which enhances the ability to track treatment outcomes and resource utilization. This specificity aids in better patient management 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 primary treatment for a lesser tuberosity fracture?

Treatment may involve conservative management with physical therapy or surgical intervention, such as open reduction and internal fixation, depending on the fracture's severity and displacement.