ICD-10 code S72.041B: Displaced fracture of base of neck of right femur

Key takeaways

ICD-10 code S72.041B covers a displaced fracture at the base of the right femoral neck, open at Gustilo Type I or II.

The 7th character B marks an open fracture at the first encounter, so it never applies to a follow-up visit.

Without a documented Gustilo grade, coders must default to the closed fracture code S72.041A.

S72.041B is billable and valid for FY2026, which runs October 1, 2025 through September 30, 2026.

Practice management software like Pabau ties code selection to the clinical note, so the chart and the claim stay in step.

ICD-10 code S72.041B is a billable ICD-10-CM diagnosis code. Its full description is: Displaced fracture of base of neck of right femur, initial encounter for open fracture type I or II.

Each part of that description does work. The fracture is displaced, so the bone ends have shifted out of alignment. It sits at the base of the femoral neck, where the neck meets the intertrochanteric region.

The injury is on the right side, seen at the initial encounter, and open at Gustilo Type I or Type II severity. The CDC/NCHS ICD-10-CM web tool confirms S72.041B as valid and billable under the current tabular list.

This code sits within ICD-10-CM Chapter 19 (Injury, poisoning and certain other consequences of external causes, S00-T88) and the S72 fracture of femur block. The parent code S72.041 is non-billable. The 7th character is mandatory to reach a valid, submittable code.

Code details at a glance

Use the quick-reference table below to verify S72.041B before submission. The code is valid for HIPAA-covered transactions throughout FY2026.

How the 7th character works in this code group

The 7th character is where most femoral neck fracture coding errors happen. Every code in the S72.041 group needs one to specify encounter type and fracture status. For S72.041B that character is B, meaning an initial encounter for an open fracture graded Gustilo Type I or II.

The CMS ICD-10 codes page publishes the full tabular list with every valid 7th character extension. The table below covers the characters you will meet most often, across both initial and subsequent encounters.

The B suffix is only valid at the initial encounter. Once the patient moves to follow-up care, the 7th character has to change to match the current healing status. The original Gustilo grade stays the same.

Other open fractures around the hip take the same B character at first presentation, including S32.492B.

Gustilo open fracture classification and ICD-10 mapping

The Gustilo-Anderson classification decides which 7th character applies to any open femoral fracture. Without the Gustilo grade, a coder cannot safely assign S72.041B. Orthopedic coders in sports medicine and occupational therapy settings meet this classification regularly in operative reports and ED notes.

Only a treating physician can set the Gustilo grade, at surgery or at wound evaluation. Coders must not infer the grade from a wound description alone. If the grade is missing, query the treating clinician before assigning S72.041B.

Grades IIIA through IIIC push the initial encounter to the C character instead, the same mapping used by S72.431C.

S72.041B vs related codes in the S72.041 family

The S72.041 parent group has several sibling codes, and knowing the family prevents laterality and encounter-type errors. The table below covers the siblings coders use most. S72.041A and S72.041B are the pair most often confused in orthopedic billing.

The rest of the femur block follows the same structure, mapped across every subcategory in S72.91XH. Detailed fracture coding references are also available through the AAPC Codify ICD-10-CM lookup.

The S72.041A and S72.041B choice is the single most common selection error in this group. Use S72.041A when the fracture is documented as closed, or when open status is not specified. Reserve S72.041B for documented open fractures with a confirmed Gustilo Type I or II grade.

Clinical documentation requirements for S72.041B

Six documentation elements must appear in the medical record before a coder can assign S72.041B. Missing any one of them forces a less specific or incorrect code. Solid clinical record management captures these elements at the point of care and prevents downstream billing delays.

• Fracture site: The record must place the fracture at the base of the neck of the femur. “Femoral neck fracture” alone is not enough without the location inside the neck.
• Laterality: Right side must be explicitly documented. “Hip fracture” without laterality forces the coder to an unspecified code.
• Displacement status: The physician must document that the fracture is displaced. Nondisplaced femoral neck fractures code to a different subcategory.
• Fracture type (open vs closed): Open status must be stated in the operative report, ED note, or attending documentation. A wound description alone will not support it.
• Gustilo grade: Type I or Type II must be documented to support the B suffix. Type IIIA, IIIB, and IIIC map to the C suffix instead.
• Encounter type: This must be an initial encounter for active fracture treatment. Follow-up visits take a subsequent encounter character, even when the rest of the description matches.

If any element is absent, the right move is a documentation query, not a coding assumption. The same six-element check drives code selection across the fracture chapter, including codes such as S82.036S.

ICD-10-CM coding guidelines for fractures of the femur

Section I.C.19 of the ICD-10-CM Official Guidelines for Coding and Reporting governs traumatic fracture coding. The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) maintain it jointly. The WHO ICD-10 browser holds the international framework underneath the CM adaptation.

• Initial vs subsequent encounter: An initial encounter applies while the patient is receiving active treatment for the fracture. A subsequent encounter applies during the healing phase, covering cast changes, hardware adjustments, and follow-up X-rays. The nature of the visit decides it, not the number of visits.
• Open vs closed default: When a fracture is not documented as open or closed, the guidelines require the coder to default to closed. Do not assign S72.041B if open status is unconfirmed.
• Displaced vs nondisplaced default: When displacement status is not documented, default to displaced under Section I.C.19.
• External cause codes: Traumatic fractures generally need an external cause code from the V00-Y99 range to explain the mechanism. For hip fractures in older patients, W19 or a more specific fall code is the usual pairing.
• Sequela coding: The S suffix applies when a patient presents with a late effect of the original fracture. Avascular necrosis of the femoral head is the usual example. Sequence the late effect first and let S72.041S follow as context. S72.411S works the same way further down the femur.
• Multiple fractures: When several fractures are present, code each one separately by site, laterality, displacement status, and encounter type.

Approximate synonyms and clinical terms

Orthopedic documentation uses several clinical terms that map to S72.041B. Recognizing them helps coders pull the right code out of operative reports and dictated notes. The terms below all describe the same clinical presentation.

• Displaced fracture of the right femoral neck, initial encounter, open type I or II
• Right hip fracture (open, Gustilo grade I or II), initial presentation
• Displaced right femoral neck base fracture, open wound
• Basicervical femoral neck fracture right side, open fracture type I or II
• Displaced fracture base of neck right femur, initial encounter open fracture
• Right proximal femur neck fracture, displaced, open type I/II, first encounter
• Fracture of neck of right femur (displaced, open), Gustilo I or II

One term that looks like a synonym is not one. A subcapital fracture sits just below the femoral head and codes to the S72.01 subcategory. A midcervical fracture codes to S72.03. Base of neck means basicervical, the segment nearest the trochanters, and that is the only site S72.041B covers.

That distinction is worth checking on every chart, because dictation rarely uses tabular language. None of the phrases above appears verbatim in the ICD-10-CM tabular list. Each maps to the same code once site, laterality, displacement, open status, grade, and encounter type all line up.

Soft tissue injuries documented alongside the fracture carry their own codes, such as S76.129S.

CPT codes commonly paired with ICD-10 code S72.041B

An open displaced fracture at the base of the right femoral neck almost always needs surgery. The CPT codes below are the common procedural pairings in orthopedic billing. Selection still depends on the surgical approach, the implant, and the case documentation, so verify every pairing against the operative report before submission.

Billing teams can move these submissions through integrated claims management rather than rekeying them into a separate system.

CPT 27236 is the most commonly paired procedure for a displaced open femoral neck fracture at an initial encounter. When the surgeon replaces the joint instead, 27130 carries its own billing rules. Reimbursement rates and coverage policies vary by payer, so do not infer them from this reference.

How Pabau keeps fracture coding tied to the clinical note

In most orthopedic practices the fracture details live in one system and the claim gets built in another. A coder reads the operative report, notes the Gustilo grade, then retypes the diagnosis code into a billing screen. Every retype is another chance to drop the 7th character.

Practice management software like Pabau closes that handoff. The diagnosis code is chosen inside the clinical note, so the code a clinician confirms is the code that reaches the claim. Your coders read the documentation and the code on one screen.

That matters most on codes like S72.041B, where a single character separates an open fracture from a closed one. When the Gustilo grade is missing, the note shows it before the claim goes out. Your team raises a query that week instead of working a denial next month.

ICD-10 code selection built into your clinical workflow

Pabau connects diagnosis code assignment directly to clinical documentation, so the right code travels with the right note every time. No copy-paste. No missed 7th characters.

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Conclusion

S72.041B rewards practices that fix documentation upstream. When the operative report names the Gustilo grade every time, the code follows in seconds. When it does not, no amount of coder experience makes the B suffix safe to use.

The trade-off worth remembering is speed against defensibility. Defaulting to S72.041A clears the claim faster, but it understates the injury and can cost the practice on reimbursement. A query costs a day and holds up under audit.

So build the grade into the operative template and let the code follow the note. Book a demo to see how Pabau keeps diagnosis codes attached to the orthopedic documentation they came from.

Continue your research

Need a structured approach to clinical note accuracy? Safer clinical notes covers documentation frameworks that cut coding query rates across specialties.

Coding a femur fracture that failed to heal? S72.451K walks through the nonunion character and the documentation it needs.

Applying the B suffix somewhere other than the femur? S62.601B shows the same open fracture logic on a smaller bone.

Billing the anesthesia side of a hip case? 01210 sets out base units and modifier rules for open hip procedures.

Coding a late effect after major hip trauma? S78.922S explains sequela sequencing when the original injury is long resolved.

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