Fracture of base of skull, right side
ICD-10 S02.101 is a billable code used to indicate a diagnosis of fracture of base of skull, right side.
A fracture of the base of the skull, specifically on the right side, is a serious injury that can result from various mechanisms such as blunt trauma, falls, or motor vehicle accidents. This type of fracture can involve the cranial fossa, which houses critical structures including the brainstem and cranial nerves. Symptoms may include headache, confusion, loss of consciousness, and neurological deficits. Diagnosis typically involves imaging studies such as CT scans or MRIs to assess the extent of the fracture and any associated intracranial injuries. Management may require surgical intervention, especially if there is significant displacement or if there are complications such as cerebrospinal fluid leaks. Close monitoring for complications like infection, hematoma, or neurological deterioration is essential. The prognosis depends on the severity of the injury and the timeliness of treatment.
Documentation must include a detailed account of the mechanism of injury, initial assessment findings, and any imaging results.
Patients presenting with head trauma from falls or accidents requiring immediate evaluation and imaging.
Ensure that all neurological assessments are documented, as they are critical for determining the severity of the injury.
Operative reports must detail the surgical approach, findings, and any repairs made to the skull base.
Surgical intervention for displaced fractures or those causing neurological compromise.
Document any intraoperative findings that may affect coding, such as additional injuries or complications.
Used when surgical intervention is required for a skull base fracture.
Operative report detailing the procedure and findings.
Ensure that the surgical approach and any complications are documented.
CT scans are the preferred imaging modality for diagnosing skull fractures, as they provide detailed images of the bony structures and can reveal associated intracranial injuries.
