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v1.0.0
ICD-10 Guide
ICD-10 CodesS02.40

S02.40

Billable

Fracture of malar, maxillary and zygoma bones, unspecified

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

Code Description

ICD-10 S02.40 is a billable code used to indicate a diagnosis of fracture of malar, maxillary and zygoma bones, unspecified.

Key Diagnostic Point:

The S02.40 code refers to fractures involving the malar (cheekbone), maxillary (upper jaw), and zygomatic (part of the cheekbone) bones, which are critical components of the facial skeleton. These fractures can occur due to various mechanisms of injury, including blunt trauma from falls, motor vehicle accidents, sports injuries, or physical altercations. Clinically, patients may present with facial swelling, bruising, pain, and deformity. Diagnostic imaging, such as X-rays or CT scans, is essential for confirming the fracture and assessing its extent. Management typically involves pain control, stabilization, and possibly surgical intervention depending on the fracture's severity and displacement. Complications can include malocclusion, facial asymmetry, and chronic pain. Accurate coding is crucial for proper reimbursement and tracking of injury patterns in epidemiological studies.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in presentation and severity of fractures
  • Need for precise imaging interpretation
  • Potential for associated injuries in polytrauma cases
  • Documentation of mechanism of injury

Audit Risk Factors

  • Inadequate documentation of the mechanism of injury
  • Failure to specify the type of fracture (e.g., open vs. closed)
  • Misclassification of fracture location
  • Lack of imaging documentation to support the diagnosis

Specialty Focus

Medical Specialties

Emergency Medicine

Documentation Requirements

Documentation must include details of the injury mechanism, initial assessment findings, and any imaging results.

Common Clinical Scenarios

Patients presenting with facial trauma after a fall or altercation.

Billing Considerations

Ensure that all injuries are documented, including soft tissue injuries that may accompany fractures.

Surgery

Documentation Requirements

Operative reports must detail the surgical approach, fixation methods, and any complications encountered.

Common Clinical Scenarios

Surgical repair of displaced zygomatic fractures.

Billing Considerations

Document any pre-existing conditions that may affect healing or surgical outcomes.

Coding Guidelines

Inclusion Criteria

Use S02.40 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the code is used only when the fracture is unspecified and that all relevant clinical information is documented

Exclusion Criteria

Do NOT use S02.40 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

21310CPT Code

Open treatment of 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 that the surgical approach and any complications are documented.

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 data accuracy and reimbursement processes. S02.40 serves as a catch-all for unspecified fractures, but coders should strive for specificity when possible.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of facial fractures, improving data accuracy and reimbursement processes. S02.40 serves as a catch-all for unspecified fractures, but coders should strive for specificity when possible.

Reimbursement & Billing Impact

reimbursement processes. S02.40 serves as a catch-all for unspecified fractures, but coders should strive for specificity when possible.

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 difference between S02.40 and more specific fracture codes?

S02.40 is used when the specific fracture type is not documented. More specific codes should be used when the fracture type and location are clearly identified in the medical record.