ICD-10-CM Billable Code

S42.115

Nondisplaced fracture of body of scapula, left shoulder

Clinical Classification Guidelines

Medical Intelligence & Overview

A nondisplaced fracture of the body of the left scapula refers to a break in the shoulder blade where the bone fragments remain properly aligned. The scapula, or shoulder blade, is a flat, triangular bone that connects the upper arm to the rest of the skeleton. When this bone suffers a fracture but stays in the correct position, it is considered nondisplaced. Such injuries typically result from trauma or impact to the shoulder region and may influence shoulder movement and stability. Recognizing this injury promptly is essential for effective management and recovery.

Causes & Symptoms

Clinical Causes: Direct blow or trauma to the shoulder during accidents or falls Sports injuries involving shoulder impact Falls onto the shoulder or outstretched arm Crashes or collisions involving the upper body High-impact activities or accidents that exert force on the shoulder girdle

Key Symptoms: Pain around the shoulder and upper back Swelling or tenderness over the shoulder blade Limited range of motion in the shoulder joint Bruising or discoloration around the shoulder Possible palpable deformity or crepitus in severe cases

Diagnostic & Treatment

Diagnosis Path: Diagnosis begins with a detailed physical examination by a healthcare professional, who will assess shoulder movement, tenderness, and swelling. Imaging tests are essential to confirm the injury. X-rays provide clear visualization of the scapula and can identify fractures. In some cases, additional imaging like CT scans may be used for detailed assessment of fracture characteristics and to rule out associated injuries. Proper diagnosis ensures appropriate treatment planning and management.

Treatment Protocols: Treatment for a nondisplaced fracture of the scapula usually involves conservative methods. The goal is to allow the bone to heal properly while minimizing complications. Common approaches include: - Rest and immobilization: Wearing a shoulder sling or brace to limit movement and provide support. - Pain management: Using over-the-counter pain relievers as recommended. - Physical therapy: Once healing progresses, guided exercises can restore shoulder strength and mobility. - Monitoring: Regular follow-up appointments and imaging to ensure proper healing and alignment. Surgical intervention is rarely needed unless there are additional injuries or complications. The healing process may take several weeks to months, depending on the severity of the fracture and individual health factors.

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 S42.115 a billable ICD-10 code?
Yes, S42.115 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report S42.115?
Clinical documentation must specify the nature of Nondisplaced fracture of body of scapula, left shoulder and any associated comorbidities for accurate reporting.

Cite this Clinical Reference