ICD-10-CM Billable Code

S42.101

Fracture of unspecified part of scapula, right shoulder

Clinical Classification Guidelines

Medical Intelligence & Overview

A fracture of the scapula, commonly known as the shoulder blade, refers to a break in the bone that forms the back part of the shoulder. When the specific part of the scapula is not identified, it is categorized under the ICD-10 code S42.101. This type of injury typically results from trauma or direct blow to the shoulder area and can significantly impact shoulder function. Accurate diagnosis and appropriate treatment are essential for proper healing and to restore mobility and strength in the shoulder.

Causes & Symptoms

Clinical Causes: Falls directly onto the shoulder or back High-impact trauma such as car accidents or sports injuries A direct blow during physical altercations Fall from a height landing on the shoulder Crushing injuries from heavy objects

Key Symptoms: Pain around the shoulder blade area, which may worsen with movement Swelling and tenderness over the shoulder blade Limited range of motion in the shoulder or arm Bruising or discoloration around the shoulder Visible deformity or abnormal positioning in severe cases Difficulty lifting or moving the arm

Diagnostic & Treatment

Diagnosis Path: X-ray imaging to visualize the bone break and assess its severity CT scans may be ordered if more detailed imaging is required to determine the exact extent of the fracture MRI scans are rarely used but can help evaluate soft tissue damage around the shoulder if needed

Treatment Protocols: Immobilization with a shoulder brace or sling to keep the bone in place during healing Pain management with over-the-counter medications or prescribed pain relievers Rest and activity modification to prevent further injury Physical therapy to regain strength, flexibility, and range of motion once initial healing occurs Surgical intervention in cases of displaced fractures or when conservative measures are insufficient, which may involve procedures to realign and stabilize the bone Follow-up imaging to monitor the healing process

Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Clinical Advice & FAQs

Billing Guidance

Is S42.101 a billable ICD-10 code?
Yes, S42.101 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report S42.101?
Clinical documentation must specify the nature of Fracture of unspecified part of scapula, right shoulder and any associated comorbidities for accurate reporting.

Cite this Clinical Reference