ICD code S02.412B – LeFort II midface fracture

Key takeaways

S02.412B is a billable ICD-10-CM code, valid for FY2025–FY2027, for a LeFort II (pyramidal) midface fracture at the initial encounter for an open fracture.

Assign the B character only when the physician explicitly documents an open fracture. Imaging alone cannot support it, and a closed fracture at the initial encounter takes S02.412A.

Most denials on this code come from 7th character mismatches, missing open-wound documentation, or sequencing errors alongside intracranial injury or orbital fracture codes.

Report an orbital floor fracture separately (S02.30XB, S02.31XB, or S02.32XB) only when the physician documents it as an injury distinct from the LeFort II pattern.

Pabau’s claims management software connects to Claim.MD for real-time eligibility checks, claim submission, and claim status tracking.

ICD-10 Code S02.412B: Definition and billable status

ICD-10 Code S02.412B is the billable ICD-10-CM code for a LeFort II fracture at the initial encounter for an open fracture. It belongs to category S02, fracture of skull and facial bones. It sits in chapter 19 of ICD-10-CM, which covers injury, poisoning, and certain other consequences of external causes.

It is valid for claim submission for FY2025–FY2027 under the CMS ICD-10 code set, and the FY2027 update effective October 1, 2026 left it unchanged.

The parent code S02.412 is a non-billable header, so a claim carrying S02.412 alone will reject. S02.412B (open, initial) and S02.412A (closed, initial) are the two billable initial-encounter codes for this fracture type, verified in the CDC/NCHS ICD-10-CM official web tool.

Clinical overview: What is a LeFort II fracture?

A LeFort II fracture is a pyramidal midface fracture. It separates a triangular segment of the central face from the cranial base and lateral facial skeleton. The fracture line runs through the nasal bones, crosses the medial orbital walls and orbital floors, and extends across the pterygoid plates. The zygoma stays attached to the skull.

René LeFort described this pattern in 1901 after cadaveric impact studies. It remains the standard classification in trauma surgery and facial fracture coding today.

Four structures are consistently involved. Clear documentation of all four helps coders confirm S02.412B is the correct assignment and supports co-coding decisions for associated structures.

• Maxilla: the central bone of the midface; the fracture line transects it bilaterally
• Nasal bones: the fracture crosses the nasal bridge, often producing telecanthus and nasal deformity
• Orbital rims and floors: the medial orbital wall and orbital floor are fractured, distinguishing LeFort II from the purely horizontal LeFort I
• Pterygoid plates: pterygomaxillary separation is present in all three LeFort types; its documentation is often cited in operative notes

The mechanism is almost always high-energy blunt trauma, such as motor vehicle collisions, assault, and falls from height. The resulting midface mobility is the classic “floating maxilla” on clinical exam. That finding supports the LeFort classification in the emergency or operative note, and recording it clearly separates S02.412B from generic facial fracture codes.

Understanding the 7th character: What does “B” mean in S02.412B?

The “B” suffix in ICD-10 Code S02.412B designates the initial encounter for an open fracture. Every fracture code in category S02 needs a 7th character. Leaving it off, or assigning the wrong letter, is one of the most common technical denial reasons for this code family. The full set of valid 7th characters for S02.412 is shown below.

Under the ICD-10-CM Official Guidelines for Coding and Reporting, the initial encounter character (A or B) covers every visit with active fracture treatment. That holds even when it is not the first visit. A patient transferred to a trauma center from an emergency department for definitive surgical repair is still at the initial encounter stage.

S02.412B vs S02.412A: Open vs closed fracture encounter

S02.412A applies when the physician documents the LeFort II fracture as closed, with no skin or mucosal breach communicating with the fracture site. S02.412B applies when the physician documents it as open, compound, or with an open wound communicating with the fracture.

That call belongs to the physician. A coder cannot assign S02.412B from CT findings of soft tissue injury or laceration unless the note calls the fracture open.

Misreading open status is the most common coding error in this code family. A high-velocity facial fracture with heavy soft tissue damage may look open on imaging. The code still follows the physician’s characterization, whatever the coder makes of the scan report. The official guidelines also code a fracture to closed when the record doesn’t say open or closed.

• Use S02.412A when: the operative note, ED note, or admitting documentation describes the fracture as closed, or never mentions an open wound or skin breach
• Use S02.412B when: the physician explicitly uses terms such as “open fracture,” “compound fracture,” or documents a wound communicating with the fracture site
• Query the physician when: notes mention lacerations, degloving, or intraoral mucosal tears without explicitly classifying the fracture as open or closed

The diagram below puts both decisions in one place, from the open/closed call through to the follow-up characters.

Code hierarchy: Parent code S02.41 and sibling LeFort codes

S02.412B sits four levels deep in the ICD-10-CM hierarchy. Understanding the parent structure helps coders navigate the tabular list and confirm they have selected the most specific billable code.

The three LeFort types are anatomically distinct. LeFort I is a horizontal maxillary fracture that does not involve the orbits. LeFort II (S02.412B) is the pyramidal fracture that does involve the orbital rims and nasal bones.

LeFort III (S02.413A/B) is a complete craniofacial separation, with the fracture line running through the frontozygomatic suture and orbital walls. Here the zygoma separates from the skull.

When several LeFort levels coexist in a panfacial fracture, code each level separately. The CMS and AHA ICD-10-CM Official Guidelines sequence multiple fractures by severity.

Includes, excludes and adjacent coding notes

Category S02 carries instructional notes that affect how S02.412B is reported alongside other codes. Coders must review these before finalizing the code set for any LeFort II claim.

Use additional code notes

• Code also any associated intracranial injury (S06.-), which must be reported separately when documented
• Use additional code for any associated open wound of the head (S01.-) when a separate wound is documented beyond the fracture site itself
• Use additional external cause code to identify mechanism of injury (e.g., V codes for motor vehicle collision, W codes for falls, X codes for assault)

Excludes2 notes (may code together)

Orbital floor fracture (S02.3-) and fracture of nasal bones (S02.2-) carry Excludes2 designations relative to S02.412B. They may be reported together when both are documented as distinct injuries. One example is an orbital blowout component beyond the orbital fracture that belongs to the LeFort II pattern. Before adding S02.3-, confirm with the physician whether the orbital floor injury is part of the LeFort II or a separate fracture.

Documentation requirements for S02.412B

The medical record must contain specific elements to support S02.412B. Missing any of the following is the main driver of audit exposure and payer denials. Sound medical billing compliance means confirming them before submission, so nobody chases them after a denial.

• LeFort II classification: the ED note, admitting H&P, or operative note must say “LeFort II,” “LeFort 2,” or “pyramidal fracture.” An equally specific description of the pattern also works. An unspecified midface or facial fracture does not support this code
• Open fracture documentation: the record needs explicit physician language, such as “open fracture,” “compound fracture,” or “open wound communicating with the fracture site.” CT or plain film findings alone are not enough
• Encounter type confirmation: the visit must be an initial encounter, with active treatment for the fracture underway. Note whether this is the first treating facility or a transfer for definitive care
• Imaging: CT of the facial bones with axial, coronal, and sagittal reformats is the standard. The radiology report should describe the fracture pattern and its involvement of the maxilla, nasal bones, and orbits
• Mechanism of injury: document the external cause (motor vehicle collision, assault, fall) to support the external cause code pairing

Commonly associated and co-reported codes

LeFort II fractures rarely present in isolation. The following codes are frequently reported alongside S02.412B. Under the ICD-10-CM Official Guidelines, the most serious injury is sequenced first. The provider decides which injury that is, based on the focus of treatment.

On the procedure side, LeFort II repair usually involves open reduction and internal fixation. CPT codes for craniofacial surgery vary by approach and extent of fixation. Payer policies govern reimbursement, and prior authorization rules differ by insurer and Medicare Administrative Contractor (MAC) jurisdiction. Confirm the CPT codes with the operative team and check payer requirements before submission.

Payer guidelines and claim submission for S02.412B

S02.412B is covered under Medicare Part A (inpatient hospital) and Part B (outpatient/professional billing) when the fracture is documented as requiring active treatment. No national coverage determination (NCD) is specific to LeFort II fracture repair.

Depending on the setting, coverage follows the inpatient prospective payment system (IPPS) diagnosis-related group (DRG) or the outpatient fee schedule. Local coverage determinations (LCDs) may apply to specific procedures in some MAC jurisdictions, so check with your facility’s compliance team.

Prior authorization rules for LeFort II repair surgery vary between commercial payers. That makes them one of the harder parts of the medical billing process for trauma cases. Most require authorization for elective, delayed repair but not for emergency operative cases.

Record the urgency classification in the operative scheduling note, because it strengthens the authorization record. A clear prior authorization process also tells schedulers which delayed repairs need payer sign-off before the operating room is booked.

Common claim denial reasons for S02.412B and how to avoid them

LeFort II claims carry extra denial risk because of the 7th character requirement, the open/closed distinction, and the co-reported codes that usually travel with them. A denial management workflow for facial trauma should screen for the four patterns below.

Wrong 7th character

Submitting S02.412 (the non-billable parent) instead of S02.412B is the top technical denial. Some EHR systems autofill the 6-character parent code when the coder searches by description rather than by full 7-character code. Always verify the full code string before finalizing the claim.

Open status unsupported by documentation

Payers auditing S02.412B claims look for explicit open-fracture language in the operative or emergency note. A note may say “laceration with underlying fracture” without calling the fracture itself open. The payer may then downcode to S02.412A or deny for insufficient documentation. Query the physician at the time of coding, before the claim goes out.

Incorrect encounter type after transfer

When an ED transfers a patient to a trauma center, the receiving facility’s first visit still counts as an initial encounter. That holds whenever active treatment is rendered there. Some coders assign “D” (subsequent encounter) at the receiving facility instead. That mismatches the claim’s DRG and can trigger a clinical validation denial.

Sequencing errors with intracranial injury

When S06.- intracranial injury codes are co-reported, principal diagnosis sequencing must reflect the condition that drove the admission. A significant traumatic brain injury may have been the main reason for the stay. Listing S02.412B as principal then conflicts with the expected DRG and can trigger a medical necessity review.

Payers flag these errors through claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs). This guide to medical billing denial codes shows which combinations point to a sequencing problem on facial fracture claims.

How claims software keeps S02.412B claims moving

Billing teams handling LeFort II claims often work across three places: the operative note, a clearinghouse portal, and a spreadsheet of claims waiting on payers. Each handoff is a chance for a skipped eligibility check or a claim that stalls without anyone noticing.

Pabau, the practice management platform we build, connects to the Claim.MD clearinghouse for real-time insurance eligibility checks. It also handles electronic claim submission and claim status tracking. Electronic remittance advice (ERA) comes back through the same connection, so a rejected facial fracture claim surfaces while the chart is still fresh.

Pabau’s claims management for surgeons keeps those statuses and remittances in one view. Recurring denial reasons on trauma claims become visible at the practice level, so you can fix the documentation habit behind them. The coding decision itself still rests with your coders and the physician’s note.

Simplify trauma billing with Pabau

Pabau connects to Claim.MD for real-time eligibility checks, electronic claim submission, and claim status tracking, so facial fracture claims don’t stall unnoticed.

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Conclusion

Treat open status as a documentation question first and a coding question second. Without a physician’s note calling the fracture open or compound, S02.412B can’t be supported. That holds however the CT reads.

The habit worth building is a physician query at the point of coding whenever lacerations appear without an open/closed call. It costs a short delay up front and saves a denial, an appeal, and a resubmission later.

Book a demo to see how Pabau handles eligibility checks, claim submission, and status tracking for your facial trauma claims.

Continue your research

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Need to read the payer’s response on a denied claim? Electronic remittance advice explains how ERA files report payments, adjustments, and denial reason codes.

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