ICD-10 Coding for Dental Trauma(S02.5XXA, S03.21XA)
Complete ICD-10-CM coding and documentation guide for Dental Trauma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Dental Trauma
S02.5Primary Range
Fracture of tooth (traumatic)
This range includes codes for traumatic fractures of teeth, which are common in dental trauma cases.
Dislocation and sprain of joints and ligaments of head
Includes codes for luxation injuries, such as tooth avulsion, which are relevant in dental trauma.
Other cysts of oral region, not elsewhere classified
Used for dentoalveolar trauma without specific tooth injury.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S02.5XXA | Fracture of tooth (traumatic), initial encounter | Use for initial encounter of a traumatic tooth fracture confirmed by radiograph. |
|
| S03.21XA | Traumatic luxation of tooth, initial encounter | Use for initial encounter of a tooth luxation injury. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for dental trauma
Essential facts and insights about Dental Trauma
Primary ICD-10-CM Codes for dental trauma
Decision Criteria
clinical Criteria
- Presence of a fracture line on radiograph
documentation Criteria
- Detailed description of fracture and tooth number
Applicable To
- Enamel-dentin fracture
- Pulp exposure
Excludes
- Cracked tooth syndrome (K03.81)
Clinical Validation Requirements
- Radiographic evidence of fracture
- Clinical examination showing fracture line
Code-Specific Risks
- Incorrect seventh character usage
- Omitting radiographic confirmation
Coding Notes
- Ensure to document the specific tooth number and type of fracture.
S03.21XA - Traumatic luxation of tooth, initial encounter
Use for initial encounter of a tooth luxation injury.
Applicable To
- Tooth avulsion
- Tooth displacement
Excludes
- Non-traumatic tooth displacement
Clinical Validation Requirements
- Clinical examination showing tooth displacement
- Radiographic confirmation of luxation
Coding Notes
Document the degree of displacement and any associated soft tissue injuries.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Dental Trauma to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S02.5XXA.
Impact
Clinical: Leads to inaccurate representation of encounter type., Regulatory: Non-compliance with ICD-10 coding standards., Financial: Potential for claim denials.
Mitigation Strategy
Always include the seventh character for encounter type., Use coding software that prompts for complete codes.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data on trauma treatment.
Mitigation Strategy
Use D7270 for tooth reimplantation/stabilization instead of periodontal codes.
Impact
Lack of detailed injury and treatment documentation can trigger audits.
Mitigation Strategy
Use structured templates and ensure all clinical findings are documented.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Dental Trauma, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Dental Trauma
Use these documentation templates to ensure complete and accurate documentation for Dental Trauma. These templates include all required elements for proper coding and billing.
Emergency Department Visit for Dental Trauma
Specialty: Emergency MedicineRequired Elements
- Patient history
- Clinical examination findings
- Radiographic findings
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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