ICD-10 code S42.253S: Displaced greater tuberosity fracture, sequela

Key Takeaways

ICD-10 Code S42.253S describes a displaced fracture of the greater tuberosity of the unspecified humerus, sequela, and is a billable ICD-10-CM code valid for FY2026 (effective October 1, 2025).

The seventh character ‘S’ designates a sequela (late effect) encounter; documentation must link a current condition directly to a prior displaced fracture of the greater tuberosity.

‘Unspecified humerus’ (digit 3) should only be used when laterality is genuinely not documented; defaulting to S42.253S when right or left is recorded is an audit risk.

Practice management software like Pabau helps orthopedic and physical therapy practices link sequela documentation to prior fracture records, flagging missing detail before the practice’s biller submits a claim.

Sequela encounters are among the most mishandled in orthopedic and post-acute billing. A patient presenting months after a shoulder fracture for ongoing stiffness, chronic pain, or reduced range of motion may require a sequela code rather than a new-injury or subsequent-encounter code, and the difference carries audit risk.

For a displaced greater tuberosity fracture of the humerus where the affected side is not documented, that code is S42.253S, distinct from a related proximal humerus fracture code like S42.223G. This reference covers the code’s full description, seventh character rules, hierarchy, sibling codes, documentation requirements, and the most common coding errors that lead to claim denials.

ICD-10 code S42.253S: Quick reference

S42.253S is a billable, specific ICD-10-CM code. It can be used to indicate a diagnosis for reimbursement purposes for FY2026. The table below captures the essential reference data medical coders and billers need at a glance.

What does S42.253S mean? Breaking down the code

ICD-10 Code S42.253S is alphanumeric shorthand for a precise clinical scenario. Each segment of the code carries distinct meaning, and understanding that structure helps coders apply the code correctly and avoid selecting a sibling code in error.

• S42 – Fracture of shoulder and upper arm. This is the parent category covering fractures of the clavicle, scapula, and humerus within the S40-S49 injuries-to-shoulder block.
• .2 – Fracture of upper end of humerus. This narrows the code to the proximal humerus rather than the shaft or distal end.
• .25 – Fracture of greater tuberosity of humerus. This subcategory specifies the anatomical site only, the greater tuberosity, the bony prominence at the top outer edge of the humerus. Displacement status is not fixed at this level; it is captured jointly with laterality by the sixth character.
• 3 – Displaced fracture, unspecified humerus. The sixth character jointly encodes displacement and laterality: 1 = right displaced, 2 = left displaced, 3 = unspecified displaced, 4 = right nondisplaced, 5 = left nondisplaced, 6 = unspecified nondisplaced. Use 3 only when the fracture is confirmed displaced but medical record documentation does not specify which arm is involved.
• S – Sequela. The seventh character identifies the encounter type as a follow-up for a condition that is the direct late effect of the prior fracture.

Taken together, ICD-10 Code S42.253S tells the payer: this patient is being seen today for a condition caused by a displaced greater tuberosity fracture that occurred in the past, and documentation does not specify whether the fracture was on the right or left side.

Anatomy: The greater tuberosity of the humerus

The greater tuberosity is the large, rounded prominence on the outer aspect of the proximal humerus. Three rotator cuff tendons, the supraspinatus, infraspinatus, and teres minor, attach directly to it. According to the WHO ICD-10 classification, fractures at this site fall within the broader category of injuries to the shoulder and upper arm.

A displaced fracture at this site is clinically significant because tendon attachment is disrupted. Even after bony union, patients commonly experience residual impingement, rotator cuff dysfunction, reduced external rotation, or chronic shoulder pain.

These are the sequela conditions that bring patients back for follow-up encounters long after the acute fracture has healed, and they are exactly what ICD-10 Code S42.253S is designed to capture. Practitioners in physical therapy and sports rehabilitation frequently encounter these sequela presentations.

Understanding sequela: When to use the ‘S’ seventh character

The three seventh characters for S42.253 represent three distinct clinical scenarios, and selecting the wrong one is one of the most audited coding errors in orthopedic billing. Each character has a specific definition under the ICD-10-CM Official Guidelines for Coding and Reporting, Section I.C.19, as maintained by the Centers for Medicare and Medicaid Services (CMS).

The ICD-10-CM guidelines note that the sequela condition itself (for example, post-traumatic shoulder stiffness or chronic shoulder impingement) should generally be coded first, with S42.253S assigned as the causal injury code. Verify current sequencing rules against the applicable fiscal year’s guidelines, because sequencing requirements can be payer-specific. Occupational therapy practices treating post-fracture functional limitations will encounter this sequencing requirement routinely.

S42.253S code hierarchy

Knowing the parent-to-child hierarchy helps coders confirm they have selected the most specific applicable code and understand why the code sits where it does in the tabular list. The full chain from block level to S42.253S is shown below. Practices handling musculoskeletal coding will recognize this S40-S49 block as one of the most commonly referenced injury blocks.

Related codes in the S42.25 greater tuberosity fracture subcategory

S42.25 covers six 6-character codes: three for displaced fractures (S42.251 right, S42.252 left, S42.253 unspecified) and three for nondisplaced fractures (S42.254 right, S42.255 left, S42.256 unspecified). Each is further extended by a seventh character for encounter type.

Using the wrong displacement, laterality, or encounter-type code when the chart documents otherwise constitutes a coding inaccuracy and can generate payer edit flags. You can verify all sibling codes against the CDC/NCHS ICD-10-CM web tool for the applicable fiscal year.

Billing and documentation requirements for S42.253S

S42.253S is a billable code, but the claim must be supported by documentation that clearly establishes the sequela relationship. Payers, particularly Medicare and Medicaid, look for specific elements before approving sequela encounter claims. Understanding HIPAA compliance is a prerequisite for managing these documentation chains correctly at medical offices. The AAPC provides additional coding guidance through its ICD-10-CM code lookup resources.

Required documentation elements for a S42.253S claim:

• Prior fracture history: The medical record or referenced external records must establish that the patient sustained a displaced fracture of the greater tuberosity of the humerus at a prior date. A prior surgical report, imaging finding, or attending physician note referencing the original fracture satisfies this requirement.
• Current sequela condition: The provider must document the specific condition being treated today (for example, post-traumatic shoulder impingement, adhesive capsulitis secondary to prior fracture, or chronic rotator cuff weakness) and link it causally to the historical fracture.
• Sequela manifestation code: Per ICD-10-CM guidelines, the sequela condition code (for example, M75.100 for a non-traumatic rotator cuff tear) is typically listed first, followed by S42.253S as the causal code. Verify sequencing with your specific payer, as local coverage determinations (LCDs) can vary.
• Provider attestation: The treating provider must attest, in their own words, that the current condition is a direct result of the historical fracture. A generic note referencing “prior shoulder injury” without specificity may not satisfy payer requirements.
• Laterality verification: As noted above, document why laterality is genuinely unspecified if using the digit-3 code. Payers may query laterality if the patient record contains prior imaging or operative notes for a specific side.

Practice management software can flag sequela codes that lack supporting documentation, helping billers catch a missing causal link in the medical record early. Structured patient record management that links historical encounters to current presentations makes this documentation chain easier to audit internally.

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Common coding errors and how to avoid them

Sequela fracture codes are disproportionately represented in orthopedic claim denial reports. The errors below are the most frequently flagged by Medicare contractors and commercial payers when S42.253S (or its sibling codes) appears on a claim. Good patient compliance documentation practices reduce the exposure substantially.

• Using ‘A’ (initial encounter) when active treatment has ended: Once the fracture is healing and the patient is no longer under active management (surgical, pharmacologic, casting), subsequent visits are either ‘D’ or ‘S’, not ‘A’. Continuing to assign S42.253A beyond the active treatment phase is a recurring audit trigger, particularly in physical therapy claims submitted months after the original injury.
• Confusing ‘D’ (subsequent) with ‘S’ (sequela): The key distinction is whether the fracture itself is still in the healing process. ‘D’ applies while healing is ongoing. ‘S’ applies after the fracture has healed and the patient is now being treated for a residual condition caused by the healed fracture. Treating a patient for shoulder stiffness six months after confirmed bony union requires ‘S’, not ‘D’.
• Omitting the sequela manifestation code: Assigning S42.253S without a preceding code for the sequela condition creates an incomplete claim. The condition being treated (stiffness, impingement, weakness, pain) must be coded; S42.253S explains why that condition exists.
• Defaulting to ‘unspecified’ humerus when laterality is available: If any document in the patient’s record (prior imaging report, operative note, ED record) identifies the affected side, the laterality-specific code (S42.251S for right or S42.252S for left) must be used. Using S42.253S when laterality is documented is considered incomplete coding under ICD-10-CM guidelines.
• Failing to establish the causal link in documentation: The provider note must explicitly connect today’s condition to the historical displaced fracture. Payers will not infer causation; it must be stated.

This same laterality-defaulting problem shows up across other musculoskeletal codes, including lower leg strain coding such as S86.819A.

ICD-10 code S42.253S in practice: Clinical scenarios

Abstract coding rules are easier to apply when grounded in realistic clinical presentations. The two scenarios below illustrate correct use of ICD-10 Code S42.253S. In both cases, the laterality of the fracture was not documented in the available records at the time of the sequela encounter. Practitioners in sports medicine and post-acute rehabilitation settings will recognize both patterns.

Scenario 1: Post-fracture shoulder impingement in physical therapy

A 54-year-old patient presents to a physical therapy practice eight months after sustaining a greater tuberosity fracture treated conservatively with a sling. Imaging at the time confirmed the fracture as displaced. The patient now reports persistent subacromial pain and loss of overhead reach.

External records from the treating orthopedic surgeon confirm displaced fracture and conservative management but do not specify right or left shoulder in the documents available to the PT practice.

The correct coding for this PT encounter: M75.40 (subacromial impingement syndrome, unspecified shoulder) sequenced first, followed by S42.253S as the causal injury code. If laterality were documented, M75.41 (right) or M75.42 (left) would apply instead. The PT note must state that the impingement is a direct consequence of the prior displaced greater tuberosity fracture.

Scenario 2: Chronic shoulder pain, post-acute care evaluation

A patient is referred by a primary care physician for evaluation of chronic right-or-left shoulder pain (side not specified in the referral) following a greater tuberosity fracture documented two years prior. The evaluating provider cannot confirm laterality from available records and documents this explicitly. The current condition: chronic post-traumatic shoulder pain limiting occupational function.

Correct coding: M25.519 (pain in unspecified shoulder joint) sequenced first, followed by S42.253S. If laterality is documented elsewhere in the chart, use M25.511 (right) or M25.512 (left) instead. The provider note must explicitly state that current shoulder pain is a sequela of the historical fracture and that laterality is unspecified in available records.

Conclusion

Sequela coding for shoulder fractures is one of the more nuanced areas of musculoskeletal ICD-10 coding. ICD-10 Code S42.253S applies to a narrow, clinically specific scenario: a patient being seen for a direct late effect of a prior displaced greater tuberosity fracture, where laterality is genuinely not documented.

Using this code correctly requires confirmed bony union, a documented sequela condition, and an explicit causal link in the provider note.

Pabau’s documentation and coding tools help orthopedic, physical therapy, and sports medicine practices track documentation completeness across sequela encounters, flagging a missing causal link before it puts a claim at risk.

To see how this applies to related shoulder-region billing, review physiotherapy compliance requirements, or the documentation demands around more complex shoulder procedures such as CPT 01634 for shoulder disarticulation.

Continue your research

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