Maxillary fracture, unspecified side
ICD-10 S02.401 is a billable code used to indicate a diagnosis of maxillary fracture, unspecified side.
A maxillary fracture refers to a break in the maxilla, the upper jawbone that forms the central part of the face, including the orbit of the eye, the nasal cavity, and the hard palate. This type of fracture can occur due to various mechanisms of injury, including blunt trauma from falls, motor vehicle accidents, sports injuries, or physical assaults. Symptoms typically include facial swelling, pain, bruising, and difficulty in chewing or speaking. Diagnosis is primarily made through clinical examination and imaging studies such as X-rays or CT scans, which help in assessing the extent of the fracture and any associated injuries. Management may involve conservative treatment with pain control and dietary modifications or surgical intervention for more complex fractures requiring realignment and stabilization. Complications can include malocclusion, chronic pain, or infection. Accurate coding is essential for proper reimbursement and tracking of injury patterns, particularly in trauma cases.
Documentation must include a detailed account of the mechanism of injury, initial assessment findings, and any imaging results.
Patients presenting with facial trauma after a fall or altercation.
Ensure that all relevant injuries are documented to support coding for multiple trauma cases.
Operative reports must detail the surgical approach, techniques used, and any complications encountered during the procedure.
Surgical repair of complex maxillary fractures requiring fixation.
Document any pre-existing conditions that may affect healing or surgical outcomes.
Used when surgical intervention is required for maxillary fracture repair.
Operative report detailing the procedure performed, materials used, and any complications.
Ensure that the surgical approach is clearly documented to support the coding.
S02.401 is used for unspecified side maxillary fractures, while S02.402 is specifically for fractures on the right side. Accurate documentation of the side of the fracture is crucial for proper coding.
