ICD-10 Code S42.265D: Nondisplaced lesser tuberosity fracture of left humerus

Key takeaways

ICD-10 code S42.265D describes a nondisplaced fracture of the lesser tuberosity of the left humerus, subsequent encounter for fracture with routine healing. It is a billable code valid for FY2026 HIPAA-covered transactions.

S42.264D is the right-side code, not the left one. The 6th character carries displacement status and laterality together, so a single digit is all that separates the two shoulders.

The 7th character D is correct only when the patient is in follow-up care and the fracture shows routine healing. Use A or B for the initial encounter, and G, K or P when healing is complicated.

Lesser tuberosity fractures sit in S42.26x, while greater tuberosity fractures sit in S42.25x. Crossing between the two groups is the most common source of wrong-code denials on proximal humerus claims.

Practice management software like Pabau integrates with Claim.MD, so codes such as S42.265D are validated against payer edits before submission. That cuts denials at follow-up visits.

ICD-10 code S42.265D covers a nondisplaced fracture of the lesser tuberosity of the left humerus, at a subsequent encounter with routine healing.

It is a billable code, valid for FY2026 HIPAA-covered transactions. The right-side equivalent, S42.264D, sits one digit away.

This reference works through the code’s clinical meaning, its 7th character logic, and the displaced versus nondisplaced distinction. It then covers the sibling codes in the S42.26x series, documentation requirements, CPT pairing and MS-DRG grouping. Billing considerations that decide whether a follow-up claim is paid close it out.

S42.265D at a glance

S42.265D is a CDC/NCHS ICD-10-CM billable code valid for HIPAA-covered transactions. The table below captures the core facts coders need before selecting it.

What does S42.265D mean? Breaking down the code

Every character in S42.265D carries a specific clinical meaning. Misread one and you are coding a different shoulder, or a different bony landmark. Here is the breakdown:

• S42 – Fracture of shoulder and upper arm. This is the parent category for all humeral, clavicular and scapular fractures.
• 4th character 2 – Fracture of the upper (proximal) end of the humerus, covering the anatomical neck, surgical neck, greater tuberosity and lesser tuberosity.
• 5th character 6 – Lesser tuberosity. This is the digit that separates the lesser tuberosity group from the greater tuberosity group, which takes a 5 here.
• 6th character 5 – Nondisplaced and left. This single digit does double duty, encoding displacement status and laterality at the same time.
• 7th character D – Subsequent encounter for fracture with routine healing. The patient has had initial active treatment and is now in follow-up, with healing progressing as expected.

That double-duty 6th character is where the S42.26x series trips coders up. Because displacement and side share one position, S42.264D and S42.265D differ by a single digit but describe opposite shoulders. According to CMS ICD-10-CM coding guidance, every character must be present and accurate before a code is billable for a given encounter type.

Anatomy: The lesser tuberosity of the humerus

The lesser tuberosity sits on the anterior surface of the proximal humerus, just medial to the bicipital groove. It is the insertion point for the subscapularis, the largest of the four rotator cuff muscles. Because the subscapularis generates significant internal rotation force, avulsion-type fractures here typically follow high-energy trauma or a forced external rotation event.

The greater tuberosity sits lateral and posterior to it, and takes the supraspinatus, infraspinatus and teres minor. The two landmarks are millimeters apart on a radiograph but sit in different ICD-10-CM subcategories. That is why imaging reports naming only “tuberosity fracture” are not codeable without clarification.

Clinicians treating these patients need to document the anatomical site explicitly. “Proximal humerus fracture” alone will not support S42.265D. The note must identify the lesser tuberosity by name.

Nondisplaced means the fractured fragments remain in their normal anatomical position, with no gap, overlap or angulation. Clinically, that often allows conservative management with a sling and staged rehabilitation. From a coding standpoint it is a distinct classification, and displaced fractures take their own codes.

7th character D: Subsequent encounter and routine healing explained

The 7th character is where most coding errors occur in this series. The S42.265 base takes seven valid 7th characters, and knowing when each applies is what keeps follow-up claims clean.

For S42.265D specifically, “D” is correct only where the treating physician documents that healing is progressing as expected. If the note describes delayed union, switch to S42.265G. If nonunion is documented, S42.265K applies instead. That distinction is a clinical determination, not a coder’s judgment call.

Displaced vs. nondisplaced: Which 6th character applies

For lesser tuberosity fractures of the left humerus, displacement status drives the 6th character. It also shapes treatment planning documentation and payer medical necessity review, particularly around therapy authorization.

Note that the displaced and nondisplaced codes for the same shoulder are not adjacent. S42.262D and S42.265D sit three digits apart, because ICD-10-CM lists all three displaced lateralities first and all three nondisplaced lateralities second. Any mental shortcut that treats displacement as “add one” produces the wrong code.

Per the ICD-10-CM Official Guidelines, a fracture not documented as displaced is coded as nondisplaced. Coders leaning on that default should still flag ambiguous notes for physician clarification before submitting. Payers running medical necessity edits may request the underlying imaging report to support a displacement determination.

Related ICD-10-CM codes for proximal humerus fractures

S42.265D sits inside the S42.26x sibling group, which covers lesser tuberosity fractures across both lateralities and both displacement statuses. Coders in orthopedic and sports medicine practices move through this set constantly. The AAPC ICD-10-CM code lookup carries the full S42.2 subcategory tree for reference.

Unspecified laterality codes such as S42.266D and S42.263D are appropriate only when the documentation genuinely does not state a side. In practice, treating physicians almost always specify laterality, so these codes should be rare. Payers and revenue cycle teams increasingly flag unspecified laterality for additional documentation requests.

Do not cross into the greater tuberosity group

The greater tuberosity has its own subcategory, S42.25, with the same six-code pattern. The codes look almost identical to the lesser tuberosity set, which is why they get swapped so often on proximal humerus claims.

Read down the grid and the trap is obvious. S42.255 is a nondisplaced left greater tuberosity fracture, and S42.265 is a nondisplaced left lesser tuberosity fracture. One digit in the fifth position is the only difference, and each of these bases still needs its 7th character before it is billable. The same one-digit logic runs through every position in the code.

Documentation requirements for S42.265D

Clean coding of S42.265D depends on the clinical note carrying four specific elements. Missing any one of them forces a query back to the provider before the claim can go out. Billing compliance audits regularly cite incomplete fracture documentation as a root cause of undercoding and claim delays.

• Laterality: The note must state “left” explicitly. Coders cannot infer laterality from an imaging report alone without physician confirmation.
• Fracture site: “Lesser tuberosity” must appear in the documentation. “Proximal humerus fracture”, “shoulder fracture” or a bare “tuberosity fracture” will not support S42.265D.
• Displacement status: The note should say “nondisplaced” or, at minimum, not describe displacement. Under ICD-10-CM guidelines, a fracture not indicated as displaced is coded as nondisplaced.
• Encounter type and healing status: For the 7th character D, the note must show a follow-up visit with healing progressing as expected. Any documented concern about healing progress calls for a different 7th character.

Many orthopedic and physical therapy practices use digital forms and structured note templates to capture these elements at every visit. That front-loads the work, so incomplete documentation is caught before the coder ever opens the chart.

Initial, subsequent or sequela: Choosing the encounter type

Encounter type is one of the most misunderstood concepts in fracture coding. The ICD-10-CM Official Guidelines are clear on this point. “Initial” and “subsequent” describe the type of care being delivered, not how many times the patient has been seen.

A practical example. A patient sustains a nondisplaced left lesser tuberosity fracture in a fall, and the emergency physician renders initial care as S42.265A.

The orthopedic surgeon fits a sling and reviews the patient at two, six and twelve weeks. Imaging shows expected callus formation each time, so all three follow-ups are coded S42.265D. Six months later the patient returns with shoulder stiffness traced to that fracture. That is S42.265S, sequenced after the code for the stiffness itself.

The CPT codes that pair with S42.265D

CPT and ICD-10-CM do not line up at this site. CPT names the surgical neck and the greater tuberosity in its shoulder fracture care codes, but it carries no code specific to the lesser tuberosity. So the diagnosis is highly specific while the procedure code is not.

The global period is the detail that decides whether a follow-up visit is paid. Fracture care codes such as 23600 carry a 90-day global period, so routine follow-up inside that window is bundled into the original payment. In that scenario S42.265D still appears on the claim, but attached to 99024 rather than a separately paid office visit.

Practices that never billed a fracture care code face a different picture. There the follow-up visit is a standard established patient E/M, supported by S42.265D and the imaging that documents routine healing. Knowing which of the two models applies before the visit is what prevents a bundling denial later.

ICD-9-CM has no code for the lesser tuberosity

There is no clean single equivalent for S42.265D in the legacy system. ICD-9-CM named the greater tuberosity but never the lesser one, and it had no laterality at all. Record conversions and historical claim reviews still reach for these codes, so the closest stand-ins are worth knowing.

The mismatch runs in one direction only. ICD-9-CM carried a named greater tuberosity code, so a legacy chart recording 812.03 tells you the site, while one recording 812.09 does not.

Use these mappings for record conversion and payer queries only. ICD-9-CM codes are not valid for FY2026 billing.

S42.265D groups to the aftercare MS-DRGs

For inpatient coders, S42.265D groups to the aftercare DRGs rather than the acute fracture ones. That reflects the nature of the encounter, which is continued management of a fracture already treated.

Which of the three applies depends on the secondary diagnoses on the claim. Osteoporosis, diabetes and other comorbidities can move a case up a tier. A surgical procedure at the same encounter changes the picture again, because the procedure code drives grouping ahead of the diagnosis.

Grouping logic shifts with each IPPS final rule. Confirm the current assignment against the CMS ICD-10 resources and your Medicare Administrative Contractor before relying on it.

Billing and reimbursement considerations

S42.265D is billable for HIPAA-covered transactions and is recognized by Medicare, Medicaid and most commercial payers. It covers subsequent encounter visits for a nondisplaced lesser tuberosity fracture of the left humerus. Several payer-specific considerations still affect clean claim submission.

• POA exemption: Subsequent encounter codes like S42.265D are generally exempt from Present on Admission reporting. Confirm against the current CMS POA exempt list for your fiscal year.
• Medical necessity pairing: S42.265D needs an appropriate procedure code alongside it. That may be an established patient E/M, 99024 inside a global period, or a therapy code. The diagnosis alone does not drive payment.
• Commercial payer variation: Some payers apply different coverage criteria to nondisplaced and displaced fractures, particularly around physical therapy authorization. Verify individual payer policies for the S42 series.
• Sequencing for inpatient encounters: When S42.265D appears on an inpatient claim, review sequencing. The fracture code is usually a secondary diagnosis, and the principal diagnosis should reflect the reason for the stay.

A clearinghouse integration can validate ICD-10 codes against real-time payer edits before a claim leaves the building. That matters most for fracture codes. The 7th character and displacement status interact with payer policy in ways that are hard to track by hand. The Claim.MD integration reaches thousands of US payers and supports CMS-1500 claim submission.

Common coding errors and how to avoid them

Five errors account for the majority of rejected or down-coded claims involving S42.265D. Each one is preventable with the right documentation habits and a pre-submission review step.

Practices with ongoing denial patterns on S42.265D and its siblings should work through the denial codes behind each rejection. That maps which payer edit fired, which finds the root cause far faster than reading raw EOBs.

How Pabau keeps fracture follow-up claims clean

In most orthopedic and physical therapy practices, the fracture code is chosen once and then copied forward. The 7th character never changes as the patient heals, and laterality is inherited from an old note. Nobody notices until the remittance advice arrives weeks later.

Pabau, practice management software built for busy clinical teams, closes that loop earlier. Structured clinical notes capture site, side, displacement and healing status at each visit. The coder then works from a complete chart rather than a query list. Cleaner claims management then checks the code against live payer edits before submission.

When a claim does come back, the remittance advice flows into the same system as an ERA/835 file. That means every S42.265D denial sits in one place. You can see whether the pattern is a 7th character issue or a laterality issue. From there you fix the workflow, rather than reworking claims one at a time.

Reduce fracture coding denials at follow-up

Pabau integrates with Claim.MD to validate ICD-10 codes against payer edits before claims go out. See how orthopedic and physical therapy practices use Pabau to catch 7th character and laterality errors on fracture follow-up visits.

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Conclusion

ICD-10 code S42.265D needs four documented elements. Those are left laterality, the lesser tuberosity as the fracture site, nondisplaced status, and a follow-up encounter with routine healing. Two of those four live in a single digit, the 6th character, which is why S42.264D and S42.265D are so easily swapped. One is the right shoulder, the other the left.

Get that digit and the 7th character right, and this code rarely causes trouble. Get either wrong and the rework compounds quickly across a busy orthopedic practice.

Pabau’s Claim.MD integration validates S42.265D and thousands of other ICD-10 codes against live payer edits before submission. To see how it works in your own workflow, book a demo.

Continue your research

Following the same fracture into nonunion? ICD-10 code S42.302K covers a left humerus nonunion, which is the case where 7th character K replaces D.

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