ICD-10 Guide

S42

Non-billable

Fracture of shoulder and upper arm

Chapter 19:Injury, poisoning and other consequences of external causes

BILLABLE STATUSNo

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/05/2025

Code Description

ICD-10 S42 is a used to indicate a diagnosis of fracture of shoulder and upper arm.

Key Diagnostic Point:

The ICD-10 Level 1 Category code S42 pertains to fractures of the shoulder and upper arm, which encompass a variety of injuries affecting the humerus, scapula, and clavicle. These fractures can result from traumatic events such as falls, sports injuries, or accidents, and may vary in severity from simple hairline fractures to complex fractures involving multiple fragments. Clinically, these injuries are significant as they can lead to complications such as impaired mobility, chronic pain, and long-term disability if not properly diagnosed and treated. The management of these fractures often involves a combination of conservative treatment, such as immobilization and physical therapy, and surgical intervention in more severe cases.

In terms of usage guidelines, S42 codes should be applied when a patient presents with a confirmed diagnosis of a shoulder or upper arm fracture. Accurate coding is crucial for effective treatment planning and for the appropriate reimbursement of services provided. It is essential for healthcare providers to be familiar with the specific subcategories under S42, as they detail the specific location and type of fracture, which can influence treatment decisions and outcomes. Proper documentation of the injury mechanism, clinical findings, and treatment plan is vital for coding accuracy and to support the medical necessity of the services rendered.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

Variety of fracture types
Potential for complications
Need for precise documentation

Audit Risk Factors

Inaccurate coding of fracture type
Insufficient documentation of injury mechanism
Failure to report complications

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Physical Medicine and Rehabilitation

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Related CPT Codes

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

As healthcare trends evolve, there is an increasing emphasis on value-based care, which underscores the importance of accurate coding in demonstrating the quality of care provided. By effectively managing and coding for shoulder and upper arm fractures, healthcare providers can contribute to improved patient outcomes and satisfaction, while also ensuring compliance with regulatory requirements and optimizing reimbursement.

ICD-9 vs ICD-10

The clinical impact of the S42 code category is significant, as accurate coding directly influences treatment pathways and patient outcomes. Fractures of the shoulder and upper arm can lead to long-term functional impairment if not managed correctly, making it essential for healthcare providers to utilize appropriate coding to facilitate timely and effective interventions. Moreover, the administrative impact includes the necessity for healthcare systems to track these injuries for quality measures and population health initiatives, which can inform resource allocation and preventive strategies. As healthcare trends evolve, there is an increasing emphasis on value-based care, which underscores the importance of accurate coding in demonstrating the quality of care provided. By effectively managing and coding for shoulder and upper arm fractures, healthcare providers can contribute to improved patient outcomes and satisfaction, while also ensuring compliance with regulatory requirements and optimizing reimbursement.

Reimbursement & Billing Impact

reimbursement.

Resources

Clinical References

•
Official ICD-10 Guidelines for S42

Coding & Billing References

•
Official ICD-10 Guidelines for S42

Frequently Asked Questions

What conditions are included in S42?

S42 includes various types of fractures affecting the shoulder girdle and upper arm, including fractures of the humerus, scapula, and clavicle, as well as dislocations and associated soft tissue injuries.

When should I use S42 codes?

S42 codes should be used when a patient is diagnosed with a fracture of the shoulder or upper arm, particularly after imaging studies confirm the presence and type of fracture.

What documentation is required for S42?

Documentation should include the mechanism of injury, clinical findings, imaging results, treatment plans, and any complications that arise during the course of treatment.

ICD-10 S42 is a used to indicate a diagnosis of fracture of shoulder and upper arm.

Key Diagnostic Point:

In terms of usage guidelines, S42 codes should be applied when a patient presents with a confirmed diagnosis of a shoulder or upper arm fracture. Accurate coding is crucial for effective treatment planning and for the appropriate reimbursement of services provided. It is essential for healthcare providers to be familiar with the specific subcategories under S42, as they detail the specific location and type of fracture, which can influence treatment decisions and outcomes. Proper documentation of the injury mechanism, clinical findings, and treatment plan is vital for coding accuracy and to support the medical necessity of the services rendered.