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ICD-10 Guide
ICD-10 CodesS02.4

S02.4

Billable

Fracture of malar, maxillary and zygoma bones

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

Code Description

ICD-10 S02.4 is a billable code used to indicate a diagnosis of fracture of malar, maxillary and zygoma bones.

Key Diagnostic Point:

Fractures of the malar (cheekbone), maxillary (upper jaw), and zygomatic bones (part of the cheek and lateral orbital wall) are common injuries resulting from trauma, often due to falls, motor vehicle accidents, or physical altercations. These fractures can lead to significant facial deformity, functional impairment, and complications such as nerve damage or sinus involvement. Clinical presentation typically includes facial swelling, bruising, pain, and possible malocclusion of teeth. Diagnosis is primarily through clinical examination and imaging studies, such as X-rays or CT scans, which help assess the extent of the fracture and any associated injuries. Management may involve conservative treatment for non-displaced fractures or surgical intervention for displaced fractures to restore anatomical integrity and function. Post-operative care and follow-up are crucial to monitor for complications such as infection or improper healing.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in fracture patterns and associated injuries
  • Need for precise documentation of fracture type and location
  • Potential for multiple codes due to associated injuries
  • Differentiation between open and closed fractures

Audit Risk Factors

  • Inadequate documentation of fracture specifics
  • Failure to capture associated injuries or complications
  • Incorrect coding of open vs. closed fractures
  • Misalignment with surgical procedures performed

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Documentation must include mechanism of injury, clinical findings, and imaging results.

Common Clinical Scenarios

Trauma cases presenting with facial injuries from falls or assaults.

Billing Considerations

Ensure accurate coding of associated injuries and any immediate interventions performed.

Surgery

Documentation Requirements

Operative reports must detail the surgical approach, findings, and any repairs made.

Common Clinical Scenarios

Surgical repair of zygomatic fractures following trauma.

Billing Considerations

Document any complications or additional procedures performed during surgery.

Coding Guidelines

Inclusion Criteria

Use S02.4 When
  • Follow ICD
  • CM guidelines for coding fractures, ensuring specificity regarding the type of fracture (e
  • , open vs
  • closed) and any associated injuries
  • Use additional codes as necessary to capture complications or related conditions

Exclusion Criteria

Do NOT use S02.4 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

21310CPT Code

Open reduction, zygomatic arch fracture

Clinical Scenario

Used when surgical intervention is required for zygomatic fractures.

Documentation Requirements

Operative report detailing the procedure and findings.

Specialty Considerations

Ensure alignment with the diagnosis of S02.4 for accurate billing.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of facial fractures, improving the accuracy of data collection and reimbursement processes. S02.4 provides granularity that was not available in ICD-9.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of facial fractures, improving the accuracy of data collection and reimbursement processes. S02.4 provides granularity that was not available in ICD-9.

Reimbursement & Billing Impact

reimbursement processes. S02.4 provides granularity that was not available in ICD-9.

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 are the common causes of fractures in the malar, maxillary, and zygoma bones?

Common causes include falls, motor vehicle accidents, sports injuries, and physical altercations. These injuries often result from direct trauma to the face.