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S42.009A
ICD-10-CM
Clavicle Fracture

Understanding Clavicle Fracture diagnosis, treatment, and recovery. Find information on Collarbone Fracture clinical documentation, medical coding, ICD-10 codes, and healthcare resources for broken clavicle injuries. Learn about clavicular fracture symptoms, causes, and treatment options for optimal patient care.

Also known as

Collarbone Fracture
Broken Clavicle
clavicular fracture

Diagnosis Snapshot

Key Facts
  • Definition : A break in the clavicle bone, which connects the breastbone to the shoulder.
  • Clinical Signs : Shoulder pain, swelling, bruising, limited arm movement, a bump or deformity over the fracture site.
  • Common Settings : Falls, sports injuries, direct blows to the shoulder, birth trauma.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC S42.009A Coding
S42.0-

Fracture of clavicle

Covers fractures of the clavicle, including closed, open, and displaced types.

T79.A

Certain early complications of trauma

Includes complications like compartment syndrome or fat embolism after a clavicle fracture.

M84.0-

Stress fracture of the clavicle

Specifically for stress fractures of the clavicle, not acute traumatic fractures.

Y93.8-

Activity, causing injury of shoulder and upper arm

Can be used to specify the activity causing the clavicle fracture, like sports.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the clavicle fracture closed?

  • Yes

    Is the fracture displaced?

  • No

    Is there a specified type of open fracture?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Broken collarbone.
Shoulder separation AC joint.
Shoulder separation SC joint.

Documentation Best Practices

Documentation Checklist
  • Clavicle fracture laterality (left/right)
  • Fracture type (e.g., displaced, comminuted)
  • Mechanism of injury (MOI) details
  • Associated injuries documentation
  • Treatment plan (e.g., conservative, surgical)

Coding and Audit Risks

Common Risks
  • Laterality Coding

    Missing or incorrect laterality (right, left, unspecified) for the clavicle fracture can lead to claim denials or inaccurate reporting.

  • Fracture Type Specificity

    Coding must specify the type of clavicle fracture (e.g., displaced, comminuted, greenstick) for proper reimbursement and data analysis. ICD-10-CM coding requires more detail than ICD-9-CM.

  • Associated Injuries

    Often, other injuries accompany clavicle fractures. Failure to code associated injuries like acromioclavicular joint injuries or brachial plexus injuries impacts reimbursement and quality metrics.

Mitigation Tips

Best Practices
  • ICD-10 S42.*, precise site/laterality for accurate coding
  • Document fracture type (e.g., displaced, comminuted) per CDI guidelines
  • Assess neurovascular status, document for compliance and risk management
  • Pain management, follow-up care instructions for improved patient outcomes
  • Image documentation (X-ray, CT) confirms diagnosis, supports medical necessity

Clinical Decision Support

Checklist
  • Mechanism of injury documented (fall, direct blow)?
  • Palpable clavicular deformity or tenderness noted?
  • Neurovascular assessment of affected extremity performed?
  • Radiographic imaging (X-ray, CT) ordered and reviewed?
  • Appropriate pain management and follow-up plan documented?

Reimbursement and Quality Metrics

Impact Summary
  • Clavicle Fracture (ICD-10 S42) reimbursement depends on fracture type, treatment (open/closed reduction), and associated injuries. Coding accuracy crucial for maximizing claim acceptance.
  • Accurate clavicle fracture coding impacts quality metrics like complication rates (e.g., nonunion, malunion), return to OR, and patient-reported outcomes.
  • Proper documentation of clavicle fracture specifics (displaced, comminuted) improves coding specificity, impacting hospital quality reporting and reimbursement.
  • Clavicle fracture claims denials can be minimized by accurate coding and documentation, reducing AR days and improving hospital revenue cycle management.

Streamline Your Medical Coding

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Frequently Asked Questions

Common Questions and Answers

Q: What are the best evidence-based non-surgical treatment options for a displaced midshaft clavicle fracture in a healthy adult patient?

A: Non-surgical management is often the preferred treatment for displaced midshaft clavicle fractures in healthy adults, provided there is no associated neurovascular compromise or open fracture. Current evidence suggests that conservative treatment with initial immobilization using a sling or figure-of-eight brace, followed by early mobilization and range-of-motion exercises, leads to similar functional outcomes and lower complication rates compared to surgical intervention in many cases. Pain management is crucial and can involve analgesics, NSAIDs, and ice application. The specific immobilization duration and rehabilitation protocol should be individualized based on patient factors such as age, activity level, and fracture displacement. Explore how our advanced imaging analysis tools can help assess fracture characteristics and inform treatment decisions. Consider implementing a standardized follow-up protocol that includes clinical examination and radiographic assessment to monitor healing progress and identify potential complications like nonunion or malunion. Learn more about the latest research on clavicle fracture management in our dedicated resources section.

Q: When is surgical intervention indicated for a clavicle fracture, and what are the preferred surgical techniques according to current best practice?

A: While most clavicle fractures heal successfully with non-operative treatment, surgical intervention is sometimes warranted. Indications for surgery include open fractures, severely displaced fractures with significant shortening (greater than 2 cm), fractures with associated neurovascular compromise, and symptomatic nonunions. Preferred surgical techniques include plate fixation, intramedullary nailing, and external fixation. Plate fixation is often considered the gold standard for complex fractures or those with significant shortening, providing excellent stability and allowing for early mobilization. Intramedullary nailing is a less invasive option but may not be suitable for all fracture patterns. The choice of surgical technique depends on factors like fracture location, displacement, and surgeon experience. Explore the benefits and drawbacks of different surgical approaches for clavicle fractures in our comprehensive surgical guide. Consider implementing a pre-operative planning protocol that includes advanced imaging studies to optimize surgical outcomes. Learn more about post-operative rehabilitation strategies for clavicle fracture patients.

Quick Tips

Practical Coding Tips
  • Code S72.0xxA for closed fracture
  • Code S72.1xxA for open fracture
  • Specify laterality (right/left)
  • Document fracture type/location
  • Check for associated injuries

Documentation Templates

Patient presents with complaints consistent with a clavicle fracture, also known as a broken clavicle or collarbone fracture.  Onset of symptoms followed [Mechanism of injury - e.g., fall on outstretched hand, direct blow to shoulder].  Patient reports [Symptom - e.g., pain, swelling, tenderness] at the site of injury.  Physical examination reveals [Physical exam findings - e.g., point tenderness over the clavicle, crepitus, deformity, limited range of motion in the affected shoulder].  Neurovascular status of the affected extremity was assessed and found to be [Neurovascular status - e.g., intact, diminished].  Radiographic imaging of the clavicle was ordered to confirm the diagnosis and assess the fracture type, location (distal, middle, proximal third), and displacement.  Differential diagnoses considered include acromioclavicular joint injury, shoulder dislocation, and contusion.  Based on clinical findings and imaging results, a diagnosis of [Type of fracture - e.g., displaced midshaft clavicle fracture, non-displaced distal clavicle fracture] was made.  Treatment plan includes [Treatment plan - e.g., sling immobilization, pain management with analgesics, referral to orthopedics for further evaluation and management, surgical intervention if indicated].  Patient education provided on proper sling use, activity modification, follow-up care, and potential complications such as malunion, nonunion, and neurovascular compromise.  ICD-10 code [Appropriate ICD-10 code - e.g., S42.001A] assigned.  Follow-up scheduled in [Duration - e.g., one week] to monitor healing progress and adjust treatment plan as needed.
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