ICD code S42.256D – Nondisplaced fracture of greater tuberosity of unspecified humerus

Key takeaways

ICD-10 code S42.256D reports a nondisplaced greater tuberosity fracture of the unspecified humerus at a follow-up visit with routine healing.

The chain runs S42 to S42.2 to S42.25 to S42.256, and the fourth character separates the humerus from the clavicle.

S42.036D reads almost the same but reports a clavicle fracture, so it never belongs on a greater tuberosity claim.

Code S42.254D for the right humerus and S42.255D for the left whenever the record names the side.

Only A, B, D, G, K, P, and S are valid 7th characters on S42 codes, which rules out Q and R.

ICD-10 code S42.256D covers a fracture healing on schedule

S42.256D sits in subcategory S42.25, fracture of greater tuberosity of humerus. Four parts of its descriptor decide whether the code fits the visit in front of you.

Nondisplaced means the fragment stayed in place, or moved so little that a sling was treatment enough. Unspecified humerus means nobody wrote right or left in the record.

The D character belongs to the follow-up visit, not to the day of the injury. Routine healing means the provider found no delayed union, no nonunion, and no malunion at this visit.

The code is valid and billable in the FY2026 ICD-10-CM code set, per the CMS ICD-10 code files. It has been reportable since October 1, 2015. Most greater tuberosity fractures are managed without surgery, so aftercare visits produce most of the claims in this family. Coders in physical therapy and rehabilitation practices meet it more often than surgeons do.

Every detail you need before the claim goes out

The table below collects the facts that decide whether this code holds up on submission.

Treat the unspecified laterality as a flag rather than a default. If the note or the radiology report names a side, code that side instead. An unspecified shoulder code invites a request for records, because the side is nearly always documented somewhere in the chart.

One wrong digit lands you in the clavicle branch

Every character narrows the diagnosis, so reading the chain from the top is the fastest way to check your work.

• S42: fracture of shoulder and upper arm, inside Chapter 19 (S00-T88).
• S42.2: fracture of upper end of humerus.
• S42.25: fracture of greater tuberosity of humerus.
• S42.256: nondisplaced fracture of greater tuberosity of unspecified humerus.
• S42.256D: the same fracture at a subsequent encounter, healing routinely.

The fourth character is where the two confusable branches split. S42.0 is the clavicle, S42.1 is the scapula, and S42.2 is the upper end of the humerus. The map below follows that split down to the billable code.

So S42.036D is not a shoulder-joint code at all. It reports a nondisplaced fracture of the lateral end of the unspecified clavicle at a routine-healing follow-up. Put it on a greater tuberosity claim and the diagnosis contradicts the imaging in the chart.

You can confirm the descriptor and the sibling codes in the CDC ICD-10-CM browser before submission. The AAPC index for S42 answers the same question in a different layout.

The 7th character carries the whole encounter story

The 7th character tells the payer where this visit sits in the healing timeline. It is also one of the most audited details in fracture coding. Category S42 uses seven of them, and nothing else is valid on a shoulder or upper arm fracture code.

Characters Q and R are the common false friend. They belong to the Gustilo open fracture extensions, which appear on forearm, femur, and lower leg codes. No S42 code carries one, so an encoder offering Q on a greater tuberosity fracture has you in the wrong family.

When D stops being the right character

D describes healing that is on track. Once the record says otherwise, the code moves with it.

Delayed healing, character G, means union is late but still coming. Nonunion, character K, means the fragments never joined. Malunion, character P, means they joined in the wrong position. At the greater tuberosity that often shows as a fragment healed above or behind the humeral head.

The change is driven by what the provider documents at that visit. A note that reads “fracture healing” without describing alignment or progress will not settle the question, and it will not survive an audit either.

Why greater tuberosity fractures pull the rotator cuff in

The greater tuberosity is the bony prominence on the outer proximal humerus, just below the humeral head.

Three rotator cuff muscles attach there: the supraspinatus, the infraspinatus, and the teres minor. That anatomy is why cuff involvement is so common, as the American Academy of Orthopaedic Surgeons (AAOS) describes.

Patients usually arrive after a fall onto an outstretched hand or a direct blow to the shoulder. An anterior shoulder dislocation can also pull the tuberosity away. What happens next depends on how far the fragment moved.

• Nondisplaced fractures: the fragment stays in position or shifts only slightly. Most orthopedic literature treats roughly 5 mm as the point where displacement becomes surgically interesting. Sling immobilization is often enough, and these are the injuries S42.256D follows.
• Displaced fractures: the fragment has migrated further, usually superiorly, and repair is considered more often. Code these to S42.253D for an unspecified humerus, not to S42.256D.
• Lesser tuberosity fractures: a different subcategory entirely, S42.26, even though the mechanism can look similar in the note.

Practices that co-manage shoulder aftercare with an orthopedic surgeon carry a specific risk. The encounter character has to be re-checked at every visit, not set once at the first appointment and left alone.

The sibling codes you switch between as healing changes

These are the codes a greater tuberosity fracture moves through, from the injury to a late effect. The last row is the clavicle code that gets picked by mistake.

The pattern repeats across Chapter 19. Encounter characters behave the same way from one fracture category to the next, so the work is knowing which characters a category allows. Our ICD-10-CM code index carries the rest of the S42 family.

What the chart must say before you use the D character

The ICD-10-CM Official Guidelines for Coding and Reporting, Section I.C.19, are direct about this. The 7th character reflects healing status at the current visit, not the status recorded at the first one. A patient at their fifth follow-up still codes to D if healing is routine that day.

• Fracture site: the note names the greater tuberosity. A bare “proximal humerus fracture” falls to a less specific code, not to S42.256D.
• Displacement status: the record states nondisplacement, or the imaging report describes the fragment in anatomical position.
• Laterality: the side, wherever the record supports it, so you can code S42.254D or S42.255D instead of the unspecified version.
• Healing status: wording such as healing well, callus formation on imaging, or alignment maintained. This is what separates D from G, K, and P.
• Encounter context: evidence that this visit is aftercare, rather than the visit where active treatment was delivered.

Query the provider before you settle for unspecified laterality. Most orthopedic notes carry an imaging reference that names the right or left shoulder, even when the assessment line does not.

Workers’ compensation claims need one more layer. The documentation has to tie the fracture back to the original incident at work. State rules vary too, so check the payer’s requirements before you submit.

Practice management software like Pabau helps here. Its digital intake forms capture the injury mechanism, imaging findings, and range of motion at every visit. The audit trail then builds as you go, rather than after a denial arrives.

The CPT codes that show up around this fracture

Diagnosis and procedure codes have to be clinically plausible together, because payers cross-check the pairing in their claim edits.

The codes below are the ones that show up around a greater tuberosity fracture, in the US CPT system. Always confirm payer coverage for a pairing before you submit it.

Codes 23620 and 23625 treat the acute fracture. They normally sit alongside an initial encounter character, not the D character. Where the fracture arrived with a dislocation, CPT code 23670 covers open treatment of both.

Global periods matter more on this code than on most. Fracture care codes commonly carry a 90-day global period that already covers routine follow-up. Billing an office visit inside that window is a frequent denial on S42.256D claims.

UK practices bill their procedures under OPCS codes, and their diagnosis coding differs too. NHS coders work from the WHO version of ICD-10, which carries no 7th character for routine healing.

How a follow-up claim moves from visit to payment

The coding decision is only half the work. Below is the path a fracture aftercare claim takes, and where it tends to stop.

1. The provider reviews the shoulder at the follow-up visit and documents that healing is on track.
2. The coder carries the diagnosis forward as S42.256D, or moves it to the side-specific code once the record names a side.
3. Charge entry ties the diagnosis to the CPT codes for that day, and checks whether the visit falls inside a global period.
4. The claim leaves electronically through your clearinghouse, and the payer’s edits test whether the pairing is plausible.
5. The remittance comes back as a payment, a denial, or a request for records.

Three problems stall it most often. The side goes out unspecified when the radiology report named it. The visit falls inside the global period nobody checked. Or healing has moved on and the D character has not.

Claims travel electronically, so the HIPAA safeguards that cover the chart cover the transmission too. Reading the remittance line by line then tells you whether a denial came from the diagnosis, the encounter character, or the payer’s own policy.

Run this check before the claim goes out

• The 7th character matches this visit’s findings, not the last visit’s.
• Laterality on the claim matches the side named in the radiology report.
• All seven characters are present, because S42.256 alone returns an edit error.
• The visit sits outside the fracture care global period, or the modifier explains why it is separate.
• For a work injury, the note links this visit back to the original incident.

Coverage rules that decide whether aftercare gets paid

The diagnosis on its own does not settle whether a follow-up service gets paid. Coverage turns on the payer, the therapy plan you documented, and sometimes an authorization you have to win first.

• Medicare and Medicaid: coverage follows the local coverage determinations issued by your Medicare Administrative Contractor, so check the LCD for your jurisdiction rather than assuming.
• Therapy authorization: extended physical therapy on a shoulder fracture commonly needs approval, and S42.256D is often a required field on the request.
• Commercial payers: visit limits differ, so record objective range-of-motion measurements to support continued care.
• Workers’ compensation: expect scrutiny of the link between the fracture and the original incident. Blanket coverage assumptions are a frequent audit failure.

An authorization request lives or dies on the paperwork attached to it. Imaging findings, measured function, and a plan that explains what happens next carry more weight than the diagnosis code alone.

Five mistakes that get S42.256D denied

1. Reaching for a clavicle code: S42.0 reports the clavicle, so S42.036D belongs to a different bone. For the greater tuberosity of the humerus, the base code is S42.256.
2. Choosing unspecified laterality: if the note says right or left, code S42.254D or S42.255D instead of S42.256D.
3. Leaving the code at D: once the record documents delayed healing, nonunion, or malunion, later visits move to G, K, or P.
4. Submitting a truncated code: S42.256 without a 7th character returns an edit error. Every S42 fracture code needs all seven.
5. Trying Q or R: those Gustilo characters belong to other fracture categories, so they are never valid on S42.

How Pabau keeps fracture follow-up claims clean

Fracture aftercare is one of the more demanding billing patterns in orthopedic and physical therapy work. The same patient returns five or six times, and the diagnosis character can change partway through.

Evidence for that change sits in a radiology report someone has to dig out. Most denials here are administrative rather than clinical.

Pabau keeps that evidence and the claim in one place. Imaging results, treatment notes, and consent forms attach to the patient record. The note behind a fracture code then sits one click from the visit it belongs to.

On the billing side, Pabau’s claim tracking is built for billing teams. It shows where every claim stands, from pending and submitted through to paid or error. It also checks that insurer-specific fields, such as membership and authorization numbers, are complete before the claim can go.

US practices submit through Claim.MD, our clearinghouse partner, which routes claims electronically and returns remittance advice and denial reason codes. Choosing the 7th character stays a coder’s judgment call. A failed claim, though, reaches you on the dashboard rather than in a month-old remittance.

Keep fracture aftercare claims moving

Pabau keeps imaging reports, treatment notes, and claim status on one patient record. Multi-visit fracture billing stops depending on who remembers which follow-up needs a new code.

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Conclusion

S42.256D is a narrow code, and that is the point of it. It says the greater tuberosity fracture is healing normally, at a follow-up visit, on a shoulder the record did not name.

Confirm the branch first, so the claim describes the humerus rather than the clavicle. Then check the side and the healing status at every visit, because both can change while the patient is still in your chair.

Book a demo to see how Pabau holds imaging reports, coded diagnoses, and claim status on one record through a full course of fracture aftercare.

Continue your research

Same fracture, healed crooked? S42.256P covers the malunion character on the same base code, and when to move off D.

Coding the displaced version instead? S42.253S walks through displaced greater tuberosity fractures at the sequela stage.

Lesser tuberosity rather than greater? S42.265D covers the neighboring S42.26 subcategory at routine healing.

Fracture arrived with a dislocation? CPT code 23670 covers open treatment of a shoulder dislocation with a greater tuberosity fracture.

Working through repeat denials? Denial management in healthcare shows how to trace a denial back to the code, the encounter, or the payer policy.

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