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ICD-10 Guide
ICD-10 CodesS22.041

S22.041

Billable

Stable burst fracture of fourth thoracic vertebra

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/23/2025

Code Description

ICD-10 S22.041 is a billable code used to indicate a diagnosis of stable burst fracture of fourth thoracic vertebra.

Key Diagnostic Point:

A stable burst fracture of the fourth thoracic vertebra (T4) occurs when the vertebra is subjected to significant axial loading, leading to a fracture that causes the vertebra to break into multiple pieces but remains stable without compromising the spinal canal. This type of fracture is often associated with trauma, such as falls or motor vehicle accidents, and can result in localized pain, tenderness, and potential neurological deficits if there is any spinal cord involvement. Patients may present with symptoms such as back pain, difficulty in movement, and in some cases, respiratory distress if associated with rib fractures or thoracic injuries. Diagnosis typically involves imaging studies like X-rays or MRI to assess the extent of the fracture and any associated injuries. Management may include conservative treatment with pain management and physical therapy, or surgical intervention if there is significant instability or neurological compromise. Understanding the implications of a stable burst fracture is crucial for appropriate treatment and rehabilitation.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between stable and unstable fractures
  • Potential for associated injuries (e.g., rib fractures, pneumothorax)
  • Need for precise documentation of fracture type and location
  • Variability in treatment approaches based on patient presentation

Audit Risk Factors

  • Inadequate documentation of fracture stability
  • Failure to document associated injuries
  • Incorrect coding of fracture type
  • Lack of clarity in treatment plans

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed imaging reports, surgical notes, and follow-up assessments.

Common Clinical Scenarios

Management of thoracic spine fractures, surgical interventions for stabilization.

Billing Considerations

Ensure clear documentation of fracture type and stability, as well as any surgical procedures performed.

Emergency Medicine

Documentation Requirements

Initial assessment notes, imaging results, and treatment plans.

Common Clinical Scenarios

Acute trauma cases presenting with chest pain and back injuries.

Billing Considerations

Accurate documentation of mechanism of injury and associated injuries is critical for coding.

Coding Guidelines

Inclusion Criteria

Use S22.041 When
  • Follow ICD
  • CM guidelines for coding fractures, ensuring to document the specific vertebra involved and the stability of the fracture
  • Include any associated injuries or complications

Exclusion Criteria

Do NOT use S22.041 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

22548CPT Code

Percutaneous vertebroplasty

Clinical Scenario

Used for stabilization of vertebral fractures.

Documentation Requirements

Pre-operative imaging and surgical notes.

Specialty Considerations

Orthopedic documentation must specify the type of fracture and treatment rationale.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of thoracic spine injuries, improving the accuracy of data collection and reimbursement processes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of thoracic spine injuries, improving the accuracy of data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

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 a stable and unstable burst fracture?

A stable burst fracture does not compromise the spinal canal or cause neurological deficits, while an unstable burst fracture may lead to spinal cord injury or significant instability requiring surgical intervention.