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ICD-10 Guide
ICD-10 CodesS42.201

S42.201

Billable

Unspecified fracture of upper end of right humerus

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

Code Description

ICD-10 S42.201 is a billable code used to indicate a diagnosis of unspecified fracture of upper end of right humerus.

Key Diagnostic Point:

An unspecified fracture of the upper end of the right humerus typically refers to a break in the proximal region of the humerus, which is the bone of the upper arm that connects the shoulder to the elbow. This type of fracture can occur due to various mechanisms, including falls, direct trauma, or sports injuries. Patients may present with shoulder pain, swelling, and limited range of motion. Diagnosis is often confirmed through imaging studies such as X-rays or MRI, which help to assess the fracture's location and severity. Treatment options may vary based on the fracture type and patient factors, ranging from conservative management with immobilization to surgical interventions such as open reduction and internal fixation (ORIF) or shoulder arthroplasty. Rehabilitation is crucial for restoring function and strength post-injury. Understanding the nuances of this code is essential for accurate billing and documentation, as it encompasses a range of potential injuries and treatment pathways.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in fracture types and treatment options
  • Need for precise documentation to specify fracture details
  • Potential for associated injuries (e.g., rotator cuff tears)
  • Differentiation from other shoulder injuries (e.g., dislocations)

Audit Risk Factors

  • Inadequate documentation of fracture specifics
  • Failure to document associated injuries
  • Misuse of unspecified codes when more specific codes are available
  • Inconsistent coding across different providers

Specialty Focus

Medical Specialties

Orthopedic Surgery

Documentation Requirements

Detailed operative reports, imaging studies, and post-operative notes are essential.

Common Clinical Scenarios

Fractures resulting from falls, sports injuries, or accidents requiring surgical intervention.

Billing Considerations

Accurate documentation of fracture type and treatment plan is critical for coding and reimbursement.

Physical Therapy

Documentation Requirements

Progress notes detailing rehabilitation protocols and patient responses.

Common Clinical Scenarios

Post-operative rehabilitation following humeral fracture repair.

Billing Considerations

Documentation must reflect the functional limitations and progress of the patient.

Coding Guidelines

Inclusion Criteria

Use S42.201 When
  • According to ICD
  • 10 guidelines, this code should be used when the specific type of fracture is not documented
  • Coders should ensure that the documentation supports the use of an unspecified code and consider more specific codes if available

Exclusion Criteria

Do NOT use S42.201 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

23470CPT Code

Arthroscopic rotator cuff repair

Clinical Scenario

Used in conjunction with S42.201 if a rotator cuff injury is also present.

Documentation Requirements

Operative report detailing the procedure and findings.

Specialty Considerations

Orthopedic surgeons must document the relationship between the fracture and any concurrent rotator cuff repair.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specificity in coding fractures, which can lead to improved patient care and more accurate reimbursement. However, the use of unspecified codes like S42.201 may indicate a need for better documentation practices.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specificity in coding fractures, which can lead to improved patient care and more accurate reimbursement. However, the use of unspecified codes like S42.201 may indicate a need for better documentation practices.

Reimbursement & Billing Impact

reimbursement. However, the use of unspecified codes like S42.201 may indicate a need for better documentation practices.

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

When should I use S42.201?

Use S42.201 when the documentation indicates an unspecified fracture of the upper end of the right humerus, and no more specific code is available.