ICD-10 code S63.615S: Unspecified sprain of left ring finger, sequela
The ICD-10 code S63.615S is a billable, specific ICD-10-CM code maintained by th...
Last Updated: August 13, 2026
Key takeaways
ICD-10 code S62.202P covers an unspecified fracture of the first metacarpal bone, left hand, at a subsequent encounter with malunion.
The code is billable and valid for HIPAA-covered transactions under the FY2026 ICD-10-CM edition, effective October 1, 2025.
The 7th character P signals malunion, meaning the fracture healed in a non-anatomical position. That is what separates S62.202P from S62.202K and S62.202D.
Pabau’s claims management software tracks subsequent-encounter codes like S62.202P across follow-up visits, so fewer claims go out with the wrong 7th character.
ICD-10 code S62.202P is a billable diagnosis code for an unspecified fracture of the first metacarpal bone, left hand. The 7th character P marks a subsequent encounter where the fracture has healed with malunion.
This guide covers the code structure, all six 7th character options, clinical context, related codes, and the documentation each one needs. The aim is to settle the P, K, and D distinction before the claim goes out.
ICD-10 code S62.202P: Full description and billable status
ICD-10 code S62.202P is a billable ICD-10-CM diagnosis code. Its full clinical description is: Unspecified fracture of first metacarpal bone, left hand, subsequent encounter for fracture with malunion.
The code became effective on October 1, 2025, and is valid for the FY2026 ICD-10-CM edition, according to the CDC/NCHS ICD-10-CM web tool.
Because S62.202P is a fully specified code, it can be used directly on insurance claims and HIPAA-covered transactions without further extension. The base code S62.202 is not itself billable, it requires a 7th character to be valid for submission.
Decoding the S62.202P code structure
Every character in an ICD-10-CM code carries a specific meaning. S62.202P is seven characters long, and each segment narrows the diagnosis from broad injury chapter to precise clinical detail.
The “unspecified” designation (02) means the fracture type was not documented as open or closed in a way that maps to a more specific sub-classification. Coders should query the treating provider if documentation allows a more precise fracture type to be captured.
Clinical context: First metacarpal fractures and malunion
The first metacarpal is the bone at the base of the thumb. Fractures here are common in sports injuries, falls on an outstretched hand, and direct blows.
Because the thumb metacarpal carries significant functional load, even minor malalignment during healing can affect grip strength and range of motion.
Malunion occurs when a fractured bone heals in a non-anatomical position. Clinically, this means the fracture has united (bone ends have bridged) but the alignment is incorrect. Patients may present at follow-up with persistent pain, limited mobility, or visible deformity.
For physical therapy practice management, tracking these subsequent-encounter diagnoses accurately is essential for episode-of-care documentation and outcome reporting.
Three encounters commonly trigger S62.202P. The first is a cast or splint removal visit where imaging confirms malunited healing. The second is an orthopedic follow-up after reduction. The third is a referral into hand rehabilitation, usually documented in occupational therapy software.
Understanding the 7th character in fracture coding
The 7th character is required for all fracture codes in the S62 category. Without it, the claim cannot be submitted. Each character maps to a distinct phase of fracture care, and selecting the wrong one misrepresents the encounter.
The ICD-10-CM Official Guidelines are published jointly by CMS and the National Center for Health Statistics. They tie the 7th character to the healing status documented at each encounter. Coders cannot retroactively apply P or K without clinical documentation of malunion or nonunion from the treating provider.
Pro Tip
Check imaging reports before assigning ICD-10 code S62.202P. The P character requires documented evidence of malunion, typically confirmed on X-ray. If the radiologist or treating physician has not explicitly noted malunion in the record, query the provider before coding P.
S62.202P vs related codes: Choosing the right code
The S62.202 family covers the left hand, unspecified fracture type. Sibling codes cover different laterality and fracture specificity. The table below helps coders navigate the most common decision points.
The most common coding error in this family is confusing K (nonunion) with P (malunion). Nonunion means the fracture has not healed at all; malunion means it has healed, but incorrectly.
Both require physician documentation, and neither can be inferred by the coder from clinical context alone. Malunion codes for the other metacarpals, such as S62.351P, follow the same rule.
Coding guidelines for S62.202P: Documentation requirements
The ICD-10-CM Official Guidelines for Coding and Reporting set specific requirements for subsequent encounter fracture coding. Meeting them consistently is what keeps coding accurate across every injury category, and clinical documentation software is where that consistency is enforced.
- Subsequent encounter definition: A subsequent encounter is any visit after initial treatment of the injury. That includes follow-ups, cast changes, physical therapy check-ins, and orthopedic reviews. It does not have to be with the same provider.
- Malunion must be documented: The physician, surgeon, or radiologist must explicitly document malunion or that the fracture has healed in a non-anatomical position. The coder cannot infer this from imaging reports alone without a provider attestation.
- Laterality is required: For S62.202P specifically, the left hand laterality is built into the code. If documentation does not confirm left-hand involvement, use the unspecified laterality code S62.209P only as a last resort.
- Open vs closed distinction: S62.202 is classified as an unspecified fracture type. The record may document a specific open fracture type, such as Gustilo I, II, or III. In that case a code from the S62.21 or S62.22 subcategory may be required. Review the tabular list before defaulting to S62.202P.
- Principal vs additional diagnosis: At subsequent encounters focused primarily on fracture management, S62.202P is the principal diagnosis. If the visit is for a complication or a related condition, sequence accordingly per ICD-10-CM sequencing rules.
HIPAA-compliant medical documentation requires that diagnosis codes accurately reflect the clinical picture at each specific encounter.
Applying S62.202P to a routine healing visit, or applying D to a visit where malunion has been confirmed, creates a compliance risk. Keeping clinical records current at each encounter is the practical safeguard against these errors.
Practices handling high volumes of fracture follow-ups need encounter-specific diagnosis codes tracked across the whole episode of care. Records that flag the current healing stage at each visit give coders what they need without a retrospective chart review.
When to use S62.202P: Common clinical scenarios
ICD-10 code S62.202P applies only when three conditions hold at once. The patient is at a follow-up visit rather than the initial fracture encounter. The fracture involves the first metacarpal of the left hand. Imaging or physician documentation confirms malunion. The same subsequent-encounter logic governs sibling codes such as S62.211D.
- Post-reduction follow-up: A patient who had closed reduction of a first metacarpal fracture returns 6 weeks later. X-ray shows the bone has healed but with angular deformity. The physician notes malunion. Use S62.202P.
- Orthopedic specialist review: A patient is referred to a hand surgeon after primary care follow-up reveals the fracture has healed in a suboptimal position. The specialist confirms malunion on imaging. S62.202P applies at this consultation.
- Cast or splint removal visit: At splint removal, imaging shows consolidation with malalignment. Provider documents malunion. S62.202P is the correct code for the removal encounter.
- Physical therapy intake: A patient is referred for occupational or physical therapy for a left thumb metacarpal fracture with documented malunion. At the initial PT evaluation, S62.202P is coded as the diagnosis driving therapy.
- Pre-surgical assessment: A patient presents for surgical consultation to discuss corrective osteotomy for a malunited first metacarpal fracture of the left hand. S62.202P is the principal diagnosis for this encounter.
CPT codes commonly paired with S62.202P
S62.202P is a diagnosis code. It is paired with CPT procedure codes on claims to establish medical necessity. The CPT codes used depend on what the provider does at the encounter, not on the ICD-10 code alone.
Payer coverage policies vary, and the combinations below represent common clinical pairings, not guaranteed reimbursable combinations.
For CPT-to-ICD-10 medical necessity crosswalks, the AAPC Codify ICD-10-CM lookup provides pairing guidance aligned with current Medicare policy. Always verify against the specific payer’s local coverage determination before submitting.
Pro Tip
When billing surgical correction of a malunited metacarpal fracture, check how the payer classifies the procedure. Some treat it as a new injury event, which calls for CPT 26615 with the appropriate modifier. Others treat it as a complication of the original fracture. Payer policies vary widely here.
How Pabau keeps 7th character coding accurate across follow-ups
At a follow-up visit, the healing status usually sits in free text written at an earlier encounter. The coder either hunts back through the chart for it or reuses the character from last time.
Practice management software like Pabau stores each diagnosis against the appointment it was recorded at. Claims management software then submits the code that belongs to that visit, and structured clinical records show which healing stage the provider actually documented.
The result is fewer denials caused by 7th character mismatches between visits, and an audit trail you can defend without a retrospective chart review.
Manage fracture follow-ups with accurate coding every time
Pabau helps practices track subsequent-encounter diagnoses across visits, flag missing healing-status notes, and submit claims with the right ICD-10 codes attached. See how it works in your practice.
Conclusion
ICD-10 code S62.202P describes a left thumb metacarpal fracture that has healed, but not correctly. The P character is not interchangeable with D or K, and the distinction rests entirely on documented evidence from the treating clinician. Getting it right protects claim integrity and supports accurate episode-of-care tracking.
Practices managing high volumes of orthopedic follow-ups can reduce 7th character errors by building encounter-specific documentation workflows directly into their practice management software. To see how Pabau supports accurate diagnosis coding and claims submission across follow-up visits, book a demo.
Continue your research
Need guidance on other ICD-10 injury codes? P10.3 shows how the same documentation-first rules apply to birth injury coding.
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Comparing claims tools before you switch? Pabau vs Waystar weighs the two claims platforms on submission, tracking, and denial handling.
Billing for fracture immobilization supplies? L0458 explains how orthotic device coding is documented and reimbursed.
Frequently asked questions
What does ICD-10 code S62.202P mean?
ICD-10 code S62.202P is a billable diagnosis code for an unspecified fracture of the first metacarpal bone, left hand. It applies at a subsequent encounter where the fracture has healed with malunion. It is valid for the FY2026 edition effective October 1, 2025. The code covers follow-up visits where imaging or physician documentation confirms the fracture has united in a non-anatomical position.
Is S62.202P a billable ICD-10-CM code?
Yes. S62.202P is a fully specified, billable ICD-10-CM code valid for HIPAA-covered transactions. The base code S62.202 is not billable on its own; it requires a 7th character extension to be submitted on a claim. S62.202P includes the required 7th character and can be used directly for reimbursement purposes.
What is the difference between S62.202P and S62.202K?
S62.202P means the fracture has healed with malunion, so the bone ends have united in a non-anatomical alignment. S62.202K means nonunion, where the bone ends have not healed at all. Both require explicit physician documentation. Malunion and nonunion are clinically distinct and lead to different treatment pathways. The 7th character must reflect the diagnosis the treating provider documented.
When should I use S62.202P vs S62.202D?
Use S62.202D when the fracture is healing normally at a subsequent encounter. Use S62.202P when the provider has documented that it healed with malunion. The distinction is based entirely on the documented healing status at each specific visit, per ICD-10-CM Official Guidelines. Coders cannot make this determination independently from clinical documentation.
What CPT codes are used with S62.202P?
Common CPT pairings include 99213 for an established patient office visit and 26615 for open treatment of the metacarpal fracture. Physical therapy evaluations use 97161-97163. The CPT code depends on the procedure performed at the encounter, not on the ICD-10 diagnosis code. Always verify payer-specific medical necessity requirements before submitting.
How is malunion different from nonunion in fracture coding?
Malunion means the fracture has healed but in an incorrect anatomical position (coded with 7th character P). Nonunion means the fracture has failed to heal and the bone ends remain separated (coded with 7th character K). Both are complications of fracture healing that typically require physician confirmation via imaging before the coder can apply the correct ICD-10 character. The WHO ICD-10 browser provides the international framework underpinning these classifications.
