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ICD-10 Guide
ICD-10 CodesS42.002

S42.002

Billable

Fracture of unspecified part of left clavicle

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/24/2025

Code Description

ICD-10 S42.002 is a billable code used to indicate a diagnosis of fracture of unspecified part of left clavicle.

Key Diagnostic Point:

A fracture of the clavicle, commonly referred to as the collarbone, can occur due to various mechanisms of injury, including falls, direct blows, or sports-related trauma. The left clavicle is particularly susceptible to fractures due to its anatomical position and the forces exerted during impact. Symptoms typically include localized pain, swelling, and a visible deformity in the shoulder area. Patients may experience difficulty in moving the arm and shoulder, which can lead to complications such as shoulder dislocations or rotator cuff injuries if not properly managed. Treatment often involves conservative measures such as immobilization with a sling, pain management, and physical therapy. In some cases, surgical intervention may be necessary to realign the bone fragments, especially in cases of displaced fractures. The prognosis is generally favorable, but recovery can vary based on the severity of the fracture and adherence to rehabilitation protocols.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in fracture types and locations within the clavicle
  • Potential for associated injuries (e.g., shoulder dislocations, rotator cuff tears)
  • Need for precise documentation of fracture characteristics
  • Differentiation between acute and chronic conditions

Audit Risk Factors

  • Inadequate documentation of fracture specifics
  • Failure to document associated injuries
  • Misclassification of fracture type
  • Inconsistent treatment documentation

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative notes, imaging reports, and post-operative care plans.

Common Clinical Scenarios

Surgical repair of displaced clavicle fractures, management of associated shoulder injuries.

Billing Considerations

Ensure clarity on the type of fracture and any surgical interventions performed.

Physical Therapy

Documentation Requirements

Progress notes detailing rehabilitation exercises, patient compliance, and functional outcomes.

Common Clinical Scenarios

Rehabilitation following clavicle fracture repair, management of shoulder mobility issues.

Billing Considerations

Document specific exercises and patient responses to therapy.

Coding Guidelines

Inclusion Criteria

Use S42.002 When
  • Follow official ICD
  • CM coding guidelines, ensuring accurate documentation of the fracture's location, type, and any associated injuries
  • Include details on treatment modalities and patient outcomes

Exclusion Criteria

Do NOT use S42.002 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

23630CPT Code

Open treatment of clavicular fracture

Clinical Scenario

Used when surgical intervention is performed for a displaced clavicle fracture.

Documentation Requirements

Operative report detailing the procedure and findings.

Specialty Considerations

Orthopedic surgeons should ensure accurate coding based on the surgical approach.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of fractures, improving the accuracy of data collection and reimbursement processes. S42.002 provides a clear designation for left clavicle fractures, aiding in clinical management and research.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of fractures, improving the accuracy of data collection and reimbursement processes. S42.002 provides a clear designation for left clavicle fractures, aiding in clinical management and research.

Reimbursement & Billing Impact

reimbursement processes. S42.002 provides a clear designation for left clavicle fractures, aiding in clinical management and research.

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 primary treatment for a left clavicle fracture?

Most left clavicle fractures are treated conservatively with a sling and physical therapy. Surgical intervention may be required for displaced fractures.