ICD code S82.402H – Open left fibula shaft fracture with delayed healing

Key takeaways

S82.402H is a billable ICD-10-CM code for a follow-up visit on an open type I or II left fibula shaft fracture with delayed healing.

The 7th character H means delayed healing, so a documented nonunion of the same fracture moves to S82.402M instead.

The Gustilo grade decides the letter, with type I or II taking H and type IIIA, IIIB or IIIC taking J.

Only the initial-encounter letter B takes an ungraded open fracture. At an H visit, take the grade from the injury record or query the surgeon.

Nonunion repair codes such as CPT 27726 need a nonunion or malunion diagnosis, so they do not belong on an H claim.

ICD-10 code S82.402H at a glance

ICD-10 code S82.402H reports a follow-up encounter for an open type I or II left fibula shaft fracture that is healing more slowly than expected. The pattern of the break is not documented, which is why the code reads “unspecified fracture.”

The code sits in category S82, whose official title is “Fracture of lower leg, including ankle.” You can confirm every row below in the CDC/NCHS ICD-10-CM browser tool and the CMS ICD-10 code files.

What does each part of S82.402H tell the payer?

Every character in S82.402H carries one clinical fact. Change any fact in the record, and the code changes with it.

• S82, lower leg: The category covers fractures of the tibia and fibula, including the ankle.
• .40, unspecified shaft fracture: The break is in the fibula shaft, and the notes do not name its pattern. A transverse, oblique, spiral, comminuted or segmental pattern has its own subcategory.
• 2, left side: The 6th character sets laterality. A 1 means right, and a 9 means the side is unspecified.
• H, subsequent encounter: Active treatment is complete, and the patient is back for care during the healing phase.
• H, open type I or II: The original fracture broke the skin and was graded Gustilo type I or II.
• H, delayed healing: The fracture is mending, but more slowly than the clinician expected. Arrested healing is a nonunion and takes a different letter.

The 7th character decides the claim

S82.402 is not billable until it carries a 7th character. That letter combines three facts: the encounter type, whether the fracture was open or closed, and how healing is going. The full set for this subcategory follows.

Read the table by healing status first. The letters G, H and J cover delayed healing. K, M and N cover nonunion, and P, Q and R cover malunion. Within each trio, the letter moves from closed to open type I or II, then to open type III.

Gustilo type: The detail that moves H to J

The open-fracture letters follow the Gustilo-Anderson classification. The treating surgeon grades the wound at the original injury, and the grade has to appear in the record. Coders take the grade from the notes and never assign it themselves.

What if the notes say “open fracture” and give no grade? The Tabular List covers that case at the first visit only. Its “open fracture NOS” inclusion term sits under the initial-encounter letter B.

The later letters E, H, M and Q have no published default. So at an H visit, take the grade from the original injury record, or query the surgeon. Never assume it. If the wound description suggests type III, query the surgeon too, because type III moves the letter from H to J in this subcategory.

The flow below puts all three record checks in order.

Delayed healing or nonunion? Picking the right neighbor

Most errors on this code come from the healing status. Delayed healing means the fracture is still progressing toward union. Nonunion means healing has stopped. The treating clinician makes that call in the notes, and the coder follows it.

Which CPT codes belong on an S82.402H claim?

An H encounter is usually a monitoring visit, so the procedure side of the claim tends to be simple. Often that means an office visit and a CPT 73590 X-ray to track progress toward union.

The harder part is knowing which fracture codes do not fit. Check payer policy and the current CPT descriptors before you bill.

The global period trips up many practices. Fibula fracture treatment codes carry a 90-day global period. Follow-up visits by the same surgeon inside that window are included in the original payment. Report those visits with CPT 99024, which records the service at no separate charge.

Documentation that keeps S82.402H defensible

An audit of S82.402H looks for four facts in the record. With all four in place, the code holds up. For the wider claim picture, see this guide to a clean claim.

• Delayed healing in the clinician’s words: The note or radiology report describes slow progress toward union. If the clinician writes nonunion, the code becomes S82.402M.
• Open fracture and its grade: The original operative or emergency note records an open fracture, graded type I or II. If that note gives no grade, query the treating surgeon.
• Left side, in this visit: The current note names the left fibula. Do not carry laterality forward from an old claim.
• Follow-up status: The note shows active treatment is complete and the patient is back for healing-phase care.

Before you submit: A five-point checklist

1. The visit is a follow-up, and active treatment of the fracture is complete.
2. The record calls the original fracture open and grades it type I or II, or the surgeon has confirmed that grade after a query.
3. The clinician documents delayed healing, with no mention of nonunion or malunion.
4. The current note confirms the left fibula shaft.
5. The visit falls outside the 90-day global period, or you report it with 99024.

Five mistakes that put the wrong letter on the claim

1. Reading H as nonunion. H means delayed healing. A documented nonunion of an open type I or II fracture is M.
2. Reaching for G on an open fracture. G is delayed healing of a closed fracture. Open type I or II takes H.
3. Ignoring a type III grade. A IIIA, IIIB or IIIC wound moves delayed healing from H to J.
4. Using an aftercare Z code. Aftercare Z codes are not used for injuries. The fracture code with its 7th character carries the follow-up.
5. Pairing H with a nonunion repair. CPT 27726 needs a nonunion or malunion diagnosis on the same claim.

Why S82.402H claims get denied

Denials on this code follow a short list of patterns. Spotting them early is the cheapest form of denial management.

To match each denial to its remittance code, use this guide to medical billing denial codes.

Includes and Excludes notes that apply

The instructional notes at category S82 apply to S82.402H too. Excludes1 means two conditions are never coded together. Excludes2 means the excluded condition is not part of this code, but both may be reported when both are present.

• Includes: Fracture of malleolus.
• Excludes1: Traumatic amputation of lower leg (S88.-).
• Excludes2: Fracture of foot, except ankle (S92.-), and periprosthetic fracture around an internal prosthetic knee or ankle joint (M97.1-, M97.2).
• Malleolus fractures sit inside S82: An isolated lateral malleolus fracture is coded to S82.6-, which belongs to the same category.
• Category notes: A fracture not described as open or closed is coded as closed. The open fracture letters follow the Gustilo classification.

What the official guidelines say about slow healing

Section I.C.19 of the ICD-10-CM Official Guidelines sets the fracture rules that sit behind this code. Following them is a basic part of medical billing compliance.

• Healing complications use their own letters: Delayed healing takes G, H or J. Nonunion takes K, M or N. Malunion takes P, Q or R.
• No aftercare Z codes for injuries: Injury aftercare uses the injury code with the right subsequent letter, D through S.
• Subsequent means after active treatment: Use a subsequent letter once active treatment is complete and the patient is in the healing or recovery phase.
• No grade means no default at H: The Tabular List lets an ungraded open fracture take B, at the initial encounter only. The Official Guidelines set no default for later letters, so query the surgeon.

Related codes worth bookmarking

These codes share most of the S82.402H description. Each one differs in a single fact, so the record decides between them.

How Pabau gets fracture follow-up claims out the door

A slow-healing fracture can mean several follow-up visits over a few months. Each visit is another claim that has to reach the payer cleanly.

Pabau, the practice management platform we build, includes claims management for US practices. Claims go to payers through our Claim.MD clearinghouse integration. Your team submits from the same system that holds the patient’s appointments and notes.

The coding decisions above stay with your coders and clinicians. Pabau handles the submission step, so the documentation work turns into a sent claim without a second system.

Send fracture follow-up claims from one system

Pabau’s claims management submits claims to US payers through the Claim.MD clearinghouse, from the same record that holds the visit notes.

Book a demo

Conclusion

Treat S82.402H as a healing-status code first. The letter H promises the payer an open type I or II fracture that is still mending. If the notes say the fracture has stopped healing, the claim needs M, and the procedures change with it.

So before you code, read the latest clinical note for the words the clinician used. Then match the letter to them, not to habit. Book a demo to see how claims management and Claim.MD submission fit around your fracture follow-up visits.

Continue your research

Need to understand how claims reach the payer? Medical claims clearinghouse guide explains how clearinghouses validate and route claims before adjudication.

Dealing with persistent fracture claim denials? Electronic remittance advice (ERA) explained covers how to read 835 remittance files and identify denial reason codes efficiently.

Want to verify patient coverage before the visit? Insurance eligibility verification outlines real-time eligibility checks that reduce subsequent-encounter billing surprises.

Frequently asked questions