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ICD-10 Guide
ICD-10 CodesS02.11

S02.11

Billable

Fracture of occiput

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 S02.11 is a billable code used to indicate a diagnosis of fracture of occiput.

Key Diagnostic Point:

A fracture of the occiput refers to a break in the bone at the back of the skull, which can occur due to trauma such as falls, motor vehicle accidents, or blunt force injuries. This type of fracture can be classified as either a linear fracture, which is a simple crack in the bone, or a comminuted fracture, where the bone is shattered into multiple pieces. Symptoms may include severe headache, neck pain, dizziness, and neurological deficits depending on the extent of the injury. The occipital bone protects the brainstem and cerebellum, making fractures in this area potentially serious, as they can lead to complications such as intracranial hemorrhage or spinal cord injury. Diagnosis typically involves imaging studies such as CT scans or X-rays to assess the fracture's nature and any associated injuries. Management may include observation, pain control, and in some cases, surgical intervention to stabilize the fracture and prevent further complications.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and severity of symptoms
  • Need for imaging studies to confirm diagnosis
  • Potential for associated injuries requiring additional coding
  • Differentiation from other skull fractures

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to capture associated injuries or complications
  • Misclassification of fracture type (linear vs. comminuted)
  • Lack of imaging documentation to support diagnosis

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Complete documentation of the patient's presentation, mechanism of injury, and any immediate interventions performed.

Common Clinical Scenarios

Patients presenting after a fall or motor vehicle accident with head trauma.

Billing Considerations

Ensure that all neurological assessments are documented to support the diagnosis and any potential complications.

Surgery

Documentation Requirements

Detailed operative reports including indications for surgery, findings, and procedures performed.

Common Clinical Scenarios

Surgical intervention for stabilization of a comminuted occipital fracture.

Billing Considerations

Document any intraoperative findings that may affect coding, such as associated injuries.

Coding Guidelines

Inclusion Criteria

Use S02.11 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the code reflects the specific type of fracture and any associated injuries
  • Document the mechanism of injury and any relevant clinical findings

Exclusion Criteria

Do NOT use S02.11 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

64721CPT Code

Craniectomy, decompressive

Clinical Scenario

Used in cases of severe occipital fractures with brain swelling.

Documentation Requirements

Operative report detailing the procedure and indications.

Specialty Considerations

Neurosurgery documentation must include pre-operative assessments and post-operative care.

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 occiput, which aids in better tracking of injury types and outcomes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of fractures, including the occiput, which aids in better tracking of injury types and outcomes.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of fractures, including the occiput, which aids in better tracking of injury types and outcomes.

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 imaging is required to confirm an occipital fracture?

CT scans are typically the preferred imaging modality for diagnosing occipital fractures due to their ability to provide detailed images of the skull and brain.