ICD 10 CM S42.155A | Description & Clinical Information

ICD 10 S42.155A describes a specific type of injury, namely a nondisplaced fracture of the left shoulder scapular neck, which is the narrow front part that separates the glenoid cavity from the rest of the scapula, resulting from a break or discontinuity of the neck of the left scapula with maintained alignment of the fracture fragments, often caused by a high impact fall, sports activities, or automobile accident, and potentially leading to a neurologic injury, with the code being applicable to the initial encounter for a fracture not exposed through a tear or laceration of the skin.

Official Description Of S42.155A

The ICD 10 CM book defines ICD 10 code S42.155A as:

Nondisplaced fracture of neck of scapula, left shoulder, initial encounter for closed fracture
Parent Code Notes: S42

Excludes1: traumatic amputation of shoulder and upper arm (S48.-)

When To Use S42.155A

The diagnosis describes by the ICD 10 CM S42.155A code is a nondisplaced scapular neck fracture of the left shoulder. This type of fracture can have several symptoms that affect a patient’s daily life, such as shoulder pain, decreased range of motion, swelling, stiffness, and weakness in the upper back and arm muscles. Patients may also experience tingling or numbness in their arms and fingers.

To diagnose this condition, several methods may be used. Providers start with a patient’s history of trauma and a physical examination to check for any signs of injury. Further tests may include laboratory examinations of blood samples to evaluate the levels of calcium and vitamin D in the body, neurological tests to evaluate muscle strength, sensation, and reflexes, and imaging techniques such as X-rays, computed tomography (CT), magnetic resonance imaging (MRI), electromyography, nerve conduction tests, and bone scans.

Depending on the severity of the fracture, different treatment options are available. A stable fracture may not require surgery, and providers may prescribe a splint or cast for immobilization of the shoulder. Physical therapy with strengthening exercises may also help patients regain mobility and strength. Medications such as steroids, analgesics, and nonsteroidal anti-inflammatory drugs (NSAIDs) can help patients manage pain and inflammation. Thrombolytics or anticoagulants can be prescribed to reduce the risk of blood clots.

On the other hand, an unstable fracture can require fixation and nerve decompression surgery. Providers may perform an open reduction and internal fixation (ORIF) procedure or even carry out a shoulder replacement surgery if necessary. These more invasive procedures aim to restore the patient’s range of motion and alleviate any pain or discomfort associated with the injury.

It is crucial for medical coders to be familiar with this diagnosis code to ensure accurate billing and coding for healthcare providers. It is essential to document all the necessary information accurately in the medical record, such as the patient’s history, treatments received, and any complications that may arise throughout the process. Through correct documentation, medical coders can accurately code the diagnosis and treatments, which is vital for healthcare providers to receive appropriate reimbursements from insurance companies.

In conclusion, the ICD 10 CM S42.155A code describes a nondisplaced scapular neck fracture of the left shoulder that can affect a patient’s mobility and quality of life. This diagnosis requires careful testing and monitoring to determine the best treatment option for each patient. Medical coders must have knowledge of this diagnosis code to ensure accurate coding and documentation to promote better patient care and efficient billing practices.

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