ICD code S02.602D – Left mandible body fracture, subsequent encounter

Key takeaways

S02.602D is a billable ICD-10-CM code for follow-up visits on a fracture of the body of the left mandible during routine healing.

7th character D applies once active treatment is complete. Use A (or B for an open fracture) during active treatment and S for late-effect sequela.

S02.602D already specifies the left side, and only the exact part of the mandible body is unspecified. Use S02.601D for the right side and S02.600D when no side is documented.

Pabau keeps operative notes and earlier claims on the patient record, so coders can confirm the side and 7th character before each follow-up claim.

ICD-10 Code S02.602D: Definition and billable status

ICD-10 Code S02.602D is the full billable code for “Fracture of unspecified part of body of left mandible, subsequent encounter for fracture with routine healing.” The side is specified as left, and only the exact part of the mandible body is unspecified.

The code sits in category S02 (Fracture of skull and facial bones) within ICD-10-CM Chapter 19. That chapter covers injury, poisoning and certain other consequences of external causes. The code is valid and billable in the current ICD-10-CM tabular list, as confirmed by the CDC/NCHS ICD-10-CM web tool.

Code details at a glance

Understanding the 7th character D: Subsequent encounter

The 7th character D means active treatment of the fracture is complete and the patient is receiving routine care while it heals. Per ICD-10-CM Official Guidelines Section I.C.19, “subsequent encounter” does not mean the patient’s second appointment in a series. It covers any encounter after active treatment ends, during the healing or recovery phase.

A practical test: use A (or B for an open fracture) while the patient is receiving active treatment. That includes the evaluation and the surgical repair. Use D when the patient returns while the fracture heals normally. Typical D visits are a follow-up check, suture removal, an IMF (intermaxillary fixation) wire check, or a post-operative imaging review.

7th character comparison: A vs D vs S for S02.602

Common coder error: AAPC coding forums flag S02.602A on the second, third, and fourth follow-up visits as a frequent facial-fracture billing mistake. Payers expect the 7th character to advance from A to D once active treatment ends. Keeping A across multiple post-operative visits can trigger medical necessity denials or retrospective audits.

What S02.602D covers and what it does not

S02.602D covers follow-up care for a fracture of the body of the left mandible during routine healing. The “unspecified” in its descriptor refers only to the part of the mandible body. The side is fixed by the code itself, which always reports the left mandible.

Before assigning it, confirm two facts in the operative report, imaging report, or clinical note. The fracture is in the body of the mandible, and it is on the left. A right-sided body fracture takes S02.601D, and a body fracture with no documented side takes S02.600D. If the chart names a more precise site, such as the angle or ramus, use that site’s code.

• Included: Fractures of the body of the left mandible where the record does not pin down the exact part of the body
• Not captured: Right-sided body fractures (S02.601D) and body fractures with no documented side (S02.600D)
• Not captured: Mandible fractures with no documented region at all, which go to S02.609D (Fracture of mandible, unspecified)
• Not captured: Left-sided fractures at a named site, which have their own codes: angle S02.652D, ramus S02.642D, subcondylar process S02.622D, and alveolus S02.672D
• Not captured: Symphysis fractures, coded to S02.66XD
• Not captured: Condylar process fractures, which belong to S02.61-D (unspecified side S02.610D, right S02.611D, left S02.612D)
• Not captured: Tooth fractures (use S02.5 codes), TMJ internal derangement (M26.6x), isolated soft-tissue facial injuries, and dental avulsion injuries

Adjacent and commonly confused ICD-10 codes

The S02.6 family codes mandible fractures by both site and side. Most sites carry an unspecified-side, a right, and a left code. The code you pick must match the site, the side and the encounter stage named in the chart, checked in that order.

Clinical context: What conditions lead to S02.602D?

S02.602D appears on subsequent-encounter claims after a patient has received initial treatment for a mandible fracture. Common mechanisms include motor vehicle collisions, assaults, sports injuries, and falls. The patient returns to an oral and maxillofacial surgeon, emergency department, or primary care provider while the fracture is still healing.

Visit types typically coded with D include post-operative ORIF checks, fixation hardware reviews, and radiograph reads for callus formation. When plain films are inconclusive, a maxillofacial CT billed as 70486 also carries S02.602D as its diagnosis. Physical therapy referrals for restricted mouth opening take D too.

Whether a follow-up visit is separately payable depends on the global surgery period of the CPT code billed at the operative encounter. That rule is one of the medical billing basics to confirm before a follow-up claim goes out.

• Post-ORIF follow-up: Most common context; patient returns 1-4 weeks after open reduction internal fixation to assess healing and hardware stability
• IMF removal visit: Coded with D when wires or elastics are removed during active healing. The removal is the primary service, and S02.602D is the supporting diagnosis
• Imaging review: Panoramic X-ray (OPG) or CT scan reviewed at a follow-up appointment to confirm callus formation and rule out displacement
• Physical therapy referral: Jaw-opening exercises and physical therapy during the healing phase, with D as the referring diagnosis code

CPT codes commonly paired with S02.602D

S02.602D is a follow-up diagnosis code. It does not appear on the initial operative claim; it appears on subsequent-encounter claims billed after the surgery or initial treatment. The table below shows procedure codes most commonly billed alongside S02.602D on those follow-up claims.

Note on global surgery periods: The initial encounter may have carried an operative CPT code. One example is 21462, open treatment of a mandibular fracture with interdental fixation. Follow-up E&M visits such as 99213 within its global period are then generally bundled into the surgical payment. Whether the visit falls inside or outside the global period depends on the specific CPT code and payer policy.

Confirm the global indicator in the CMS Physician Fee Schedule lookup before billing a separate E&M alongside S02.602D. In oral and maxillofacial surgery practices, tracking the global period end date at the patient level prevents accidental unbundling.

Documentation requirements for S02.602D

The medical record must substantiate three things to support S02.602D. It confirms a left mandible body fracture, shows the visit is a follow-up rather than the initial encounter, and notes routine healing without complication. Per CMS ICD-10-CM coding guidelines, supporting documentation for injury codes must include the mechanism and clinical status at each encounter.

• Fracture confirmation: Reference to the original diagnosis (date of injury, imaging confirming fracture) or the treating clinician’s prior note establishing the diagnosis
• Active treatment or monitoring: A note describing the current clinical activity (hardware check, suture removal, range-of-motion assessment) rather than purely passive surveillance
• Healing phase documentation: Explicit language such as “healing without complication,” “callus visible on panoramic X-ray,” or “no signs of nonunion.” That wording justifies D rather than G (delayed healing) or K (nonunion)
• Side and site: State “left” and “body of mandible” in the note, and keep both consistent with the imaging report. A chart that says “right” or gives no side cannot support S02.602D
• Treating clinician and date of service: Required on every claim; missing provider identification is a technical denial cause unrelated to the code itself

Submitting a clean claim for a subsequent-encounter fracture visit means the record must address all of the above before the claim leaves the practice. Missing any element leaves the claim exposed to a medical necessity challenge on audit.

Why claims with S02.602D get denied and how to fix them

Denials on S02.602D claims cluster around a small set of recurring errors. Most are preventable with correct character selection and complete documentation before submission. Denial management workflows for facial-fracture claims should flag each of the patterns below at the coding review stage, before the claim reaches the clearinghouse.

Payer and coverage considerations

Medicare and most Medicaid plans cover medically necessary mandible fracture treatment and the associated follow-up visits. Subsequent-encounter visits billed with S02.602D generally fall within the global surgery period framework when a covered procedure was performed at the initial encounter. Separately billed follow-up services are covered only outside the global period, and only when the CPT code is not bundled into the initial payment.

Private payer variation is significant. Some commercial plans run laterality edits that compare the side in the diagnosis code with the side in the procedure documentation. A left-coded claim against a right-sided operative note will pend for record review.

Others apply frequency edits that limit the number of follow-up visits reimbursed within a defined healing window. Pre-authorization is typically required for additional imaging (CT, cone-beam CT) ordered during the healing phase, even when the fracture itself was originally authorized.

• Medicare LCD considerations: No specific Local Coverage Determination governs S02.602D directly. Coverage follows the LCD for the associated procedure, such as the jaw fracture repair LCD in the applicable MAC jurisdiction
• Pre-authorization for specialist referral: The OMS may refer the patient to physical or occupational therapy for jaw-opening exercises. The therapist’s payer may then require authorization with S02.602D as the referring diagnosis
• Coordination of benefits: In trauma cases, workers’ compensation or automobile insurance may be the primary payer. Verify coordination of benefits before billing medical insurance to avoid duplicate payments

Reviewing medical billing denial codes for facial fracture claims helps billing teams anticipate which CARC codes a denial will carry. Understanding the denial reason at the code level shortens the appeals cycle considerably.

How Pabau keeps S02.602D follow-up claims clean

S02.602D denials usually trace back to manual steps. A coder copies S02.602A forward to every follow-up visit, or keys the side without rereading the operative note.

Pabau, the practice management and billing platform we build, keeps the operative note, imaging reports and earlier claims on the same patient record. Coders working in its claims management software can check the side and 7th character billed at earlier visits before coding today’s follow-up.

In the US, Pabau submits claims electronically through Claim.MD to thousands of payers and runs real-time eligibility checks. Claim status and ERA remittances come back to the same record. A denial on an S02.602D follow-up then sits next to the notes you need to correct and appeal it.

Code every jaw fracture follow-up with confidence

Pabau keeps operative notes, earlier claims and remittances on one patient record. Coders confirm the side and 7th character before each follow-up claim goes out through Claim.MD.

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Conclusion

S02.602D fits a claim only when three facts line up. The fracture sits in the body of the left mandible, the visit is a follow-up, and healing is routine. If any one of them changes, the claim needs a different code.

Advance the 7th character from A to D once active treatment ends, and move on to G, K or S when the clinical picture changes. Check the side against the operative and imaging notes on every claim, because the code already commits the claim to the left mandible. To see how Pabau tracks those decisions across a patient’s follow-up visits, book a demo.

Continue your research

Want to understand how clearinghouse claim submission works? Medical claims clearinghouse guide explains how electronic claims are validated, batched, and forwarded to payers.

Looking for a reference on ERA and remittance processing? Electronic remittance advice (ERA) explains how 835 remittance files carry CARC denial codes back to billing teams after adjudication.

Chart names the mandible body but no side? ICD-10 Code S02.600D covers the unspecified-side follow-up code for the same fracture site.

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