ICD-10 Coding for Proximal Humerus Fracture(S42.231A, S42.201K)
Complete ICD-10-CM coding and documentation guide for Proximal Humerus Fracture. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Proximal Humerus Fracture
S42.20-S42.29Primary Range
Fractures of the humerus
This range includes all types of proximal humerus fractures, specifying laterality, displacement, and encounter type.
Periprosthetic fracture around internal prosthetic joint
Used for fractures around prosthetic shoulder joints, requiring sequencing with the fracture cause.
Pathological fracture in neoplastic disease
Used for fractures due to underlying conditions like neoplasms or osteoporosis.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S42.231A | Displaced fracture of greater tuberosity of left humerus, initial encounter | Use for initial encounters of displaced fractures of the left proximal humerus. |
|
| S42.201K | Nonunion of fracture of left humerus | Use for nonunion cases following surgical intervention. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for proximal humerus fracture
Essential facts and insights about Proximal Humerus Fracture
Primary ICD-10-CM Codes for proximal humerus fracture
Decision Criteria
clinical Criteria
- Presence of a displaced fracture confirmed by imaging
documentation Criteria
- Detailed description of fracture pattern and laterality
Applicable To
- 3-part displaced fracture
Excludes
- Pathological fracture (M84.52-)
Clinical Validation Requirements
- X-ray confirmation of displacement
- Documentation of Neer classification
Code-Specific Risks
- Incorrect laterality
- Missing displacement details
Coding Notes
- Ensure documentation includes Neer classification and displacement measurements.
S42.201K - Nonunion of fracture of left humerus
Use for nonunion cases following surgical intervention.
Applicable To
- Nonunion after ORIF
Excludes
- Acute fracture (S42.20-S42.29)
Clinical Validation Requirements
- Imaging showing nonunion
- Surgical history indicating previous ORIF
Coding Notes
Ensure follow-up care is documented with appropriate aftercare codes.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Periprosthetic fracture around internal prosthetic joint
M97.3-Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Proximal Humerus Fracture to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S42.231A.
Impact
Clinical: May lead to incorrect treatment planning., Regulatory: Increases risk of audit queries., Financial: Potential for denied claims due to incomplete coding.
Mitigation Strategy
Always include laterality in fracture documentation., Use templates that prompt for laterality.
Impact
Reimbursement: May lead to lower DRG assignment and reimbursement., Compliance: Increases risk of audit and non-compliance., Data Quality: Reduces accuracy of clinical data and research.
Mitigation Strategy
Ensure documentation includes specific fracture details such as displacement and laterality.
Impact
High risk of audit when unspecified codes are used despite available details.
Mitigation Strategy
Ensure detailed documentation to support specific code selection.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Proximal Humerus Fracture, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Proximal Humerus Fracture
Use these documentation templates to ensure complete and accurate documentation for Proximal Humerus Fracture. These templates include all required elements for proper coding and billing.
Initial encounter for displaced proximal humerus fracture
Specialty: OrthopedicsRequired Elements
- Mechanism of injury
- Fracture type and displacement
- Imaging results
- Neer classification
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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