ICD-10-CM Billable Code

S02.41

LeFort fracture

Clinical Classification Guidelines

Medical Intelligence & Overview

A LeFort fracture is a specific type of facial fracture affecting the midface area, typically caused by a high-impact injury. These fractures are classified into different types based on the pattern and location of the fracture lines. Recognizing and diagnosing a LeFort fracture is crucial because it involves the structural integrity of the midface and can affect both appearance and function.

Causes & Symptoms

Clinical Causes: Motor vehicle accidents Falls from significant heights Physical assaults or blows to the face Sports injuries involving high impact Crushing injuries in workplace accidents

Key Symptoms: Facial swelling and bruising Pain or tenderness in the midface area Nasal bleeding or bleeding inside the mouth Facial deformity or changes in facial symmetry Difficulty opening the mouth or moving the jaw Numbness or tingling in the face, especially around the cheeks and upper lip Impaired vision or orbital injuries (if the orbit is involved) Palpable step-offs or crepitus in the facial bones

Diagnostic & Treatment

Diagnosis Path: Diagnosis involves a comprehensive physical examination by a healthcare professional, who assesses facial stability, tenderness, and deformity. Imaging studies are essential for confirming the diagnosis and determining the fracture pattern. Commonly used tools include:

Treatment Protocols: Treatment of a LeFort fracture usually requires surgical intervention to repair the broken bones and restore facial structure. The approach depends on the specific type and severity of the fracture:

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 S02.41 a billable ICD-10 code?
Yes, S02.41 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report S02.41?
Clinical documentation must specify the nature of LeFort fracture and any associated comorbidities for accurate reporting.

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