S02.40ED

🧬 ICD-10 CM S02.413D — LeFort III Fracture, Subsequent Encounter for Fracture With Routine Healing

Billable Code Confirmed

ICD-10 CM S02.413D is a 7-character code: S02.41 is LeFort fracture, the 6th character 3 is type III, and the 7th character D is subsequent encounter for fracture with routine healing. It is a valid, billable code for FY2026 claims.^1,2

Non-Billable Parent Codes

S02.4 (Fracture of malar, maxillary and zygoma bones) is a non-billable category that lacks fracture type, laterality or site, and encounter character.^1,6 S02.41 (LeFort fracture) is a non-billable subcategory that lacks the LeFort type and the 7th character.

Clinical Context

Choose D only when active treatment is complete and the patient is receiving routine care during healing or recovery, such as follow-up, device adjustment or removal, or medication adjustment. The LeFort III pattern is a craniofacial separation through the nasofrontal suture, orbits, and zygomatic arches.⁵

Code Classification

This is an ICD-10-CM diagnosis code from the Injury chapter, and it is not a procedure code.

---

🔍 Code Description

ICD-10 CM S02.413D describes a LeFort III fracture, which is a craniofacial dysjunction, at a follow-up encounter where healing is progressing normally. It is reported after active treatment is finished, and the same fracture reported at the initial visit would be S02.413A (closed) or S02.413B (open).⁵ The type is built into the code, so the record needs to document LeFort III specifically. Unlike the S02.40 zygomatic and malar codes, there is no laterality character.³
The 7th character is what separates this code from its siblings: S02.413G is subsequent encounter with delayed healing, S02.413K is subsequent encounter with nonunion, and S02.413S is sequela.³ Pick the character from the provider’s documentation of healing status at that visit. The treatment phase alone does not decide the character.

---

🌳 Code Tree / Hierarchy

S02 Fracture of skull and facial bones ❌ Non-billable
│
├── S02.40 Fracture of malar, maxillary and zygoma bones, unspecified ❌ Non-billable
│ │
│ ├── S02.400D Malar fracture, unspecified side, subsequent encounter, routine healing ✅ Billable
│ └── S02.401D Maxillary fracture, unspecified side, subsequent encounter, routine healing ✅ Billable
│
├── S02.4 Fracture of malar, maxillary and zygoma bones ❌ Non-billable
│ │
│ ├── S02.411D LeFort I fracture, subsequent encounter for fracture with routine healing ✅ Billable
│ ├── S02.412D LeFort II fracture, subsequent encounter for fracture with routine healing ✅ Billable
│ └── S02.413D LeFort III fracture, subsequent encounter for fracture with routine healing ◀ THIS CODE ✅ Billable
│
└── S02.42 Fracture of alveolus of maxilla ❌ Non-billable
  │
  └── S02.42XD Fracture of alveolus of maxilla, subsequent encounter, routine healing ✅ Billable

Specificity Matters: LeFort Type and Healing Status

The LeFort level (I, II, III) and the 7th character each change the code, so vague documentation like “midface fracture follow-up” can fall to S02.92XD (unspecified fracture of facial bones). Query the provider for the type and for routine versus delayed healing or nonunion.

Tip

Assign a single 7th character per fracture per encounter. Do not report D together with A, B, G, K, or S for the same fracture on the same date.

---

✅ Includes

• The S02.4 category applies to fracture of the superior maxilla, fracture of the upper jaw (bone), and fracture of the zygomatic process of the temporal bone.^1,6
• LeFort fracture is the S02.41 subcategory term, and type III maps to S02.413D at follow-up.

---

❌ Excludes

Excludes 1

• No code-level Excludes1 note was retrieved for S02.413D. Verify section-level S02 notes in your encoder.

Danger

The most common error is reporting the initial-encounter A or B character for a follow-up visit because the fracture was “just treated.” If active treatment is complete and the patient is healing normally, D applies. Keep the 7th character consistent with the phase of care.

Excludes 2

• Code any associated injury separately when documented, such as brain injury, eye or orbit injury, cranial nerve injury, or open wound of head. Confirm the exact “code also” and Excludes2 notes at S02 in your encoder.

---

📋 Clinical Overview

LeFort Level and Healing Phase

LeFort fractures are classified by the level of midface separation. Type I is a horizontal maxillary fracture above the teeth, type II is pyramidal through the nasal bridge and infraorbital rim, and type III separates the midface from the skull base. At follow-up, the 7th character carries the healing status.⁵

Feature	S02.413D	Related S02.411D	Related S02.412D
Fracture pattern	LeFort III: craniofacial dysjunction with the midface separated from the cranial base.	LeFort I: horizontal maxillary fracture above the dental roots.	LeFort II: pyramidal fracture through the nasal bridge and infraorbital rim.
Encounter phase	Subsequent encounter, routine healing.	Subsequent encounter, routine healing.	Subsequent encounter, routine healing.
Documentation key	Provider must document LeFort type III and healing status.	Provider must document LeFort type I.	Provider must document LeFort type II.

Important

A CDI trigger is a note that says only “facial fracture follow-up” or “midface fracture.” Query for the LeFort type and for routine healing versus delayed healing or nonunion so the correct 7th character is assigned.

Manifestations & Symptom Burden

• Midface mobility or malocclusion may persist during healing and is monitored at follow-up.
• Facial swelling, ecchymosis, and pain typically taper during routine healing.
• Periorbital or nasal findings such as diplopia or epiphora can accompany this fracture pattern. Code them separately only when documented as a condition being managed.
• Residual numbness from infraorbital nerve involvement may be monitored.

Tip

Code associated symptoms and injuries only when the provider documents them as relevant to the encounter, and follow the “code also” instruction at S02.

---

💰 HCC Risk Adjustment

Field	Value
ICD-10-CM Code	S02.413D
HCC Category	N/A — not expected to map to a CMS-HCC
RAF Impact	None expected on its own
Annual Capture	Not required for this code
Payer Note	Verify with your payer’s current model mapping

Confirm in the CMS mappings or the AAPC Risk Adjustment Search Tool before relying on it.

---

🏥 MS-DRG Assignment

Field	Value
MDC	MDC 08 — Musculoskeletal System and Connective Tissue3
DRG with MCC	559 — Aftercare, Musculoskeletal System and Connective Tissue with MCC
DRG with CC	560 — Aftercare, Musculoskeletal System and Connective Tissue with CC
DRG without CC/MCC	561 — Aftercare, Musculoskeletal System and Connective Tissue without CC/MCC

CMS’s v40 definitions manual lists S02.413D in the MDC 08 diagnosis assignment list.³ The DRG numbers above are my inference from that placement and need verification in your FY2026 grouper. A D code is seldom the principal diagnosis for an inpatient stay. When an admission is for the fracture itself, the A/B character and the procedure drive the DRG.

• LCD/NCD: I found no NCD specific to this code.
• Contractor article A57215 (MRI and CT Scans of the Head and Neck) lists S02.413D among the ICD-10-CM codes that support medical necessity.⁴
• Confirm A57215 applies to your MAC jurisdiction and is still active for 2026.

---

🔗 Related ICD-10-CM Codes

Same fracture, other 7th characters: S02.413A, S02.413B, S02.413G, S02.413K, S02.413S^3,5

Related facial fracture follow-up codes: S02.411D, S02.412D, S02.42XD, S02.401D, S02.609D, S02.92XD³

---

🛠️ Commonly Associated CPT Codes

• 21432: Open treatment of craniofacial separation (LeFort III type) with wiring and/or internal fixation. It is typically reported with the initial-encounter A/B diagnosis and not with D.
• 99024: Postoperative follow-up visit within the global period. It is reported at no charge for tracking and is used when the same surgeon sees the patient for follow-up.
• 99213: Established-patient office visit. Use it for follow-up by a provider outside the surgeon’s global package, or for an unrelated problem with -24.
• 70486: CT maxillofacial area without contrast. It is commonly used to assess healing and alignment; check A57215 for coverage.⁴
• 70150: Radiologic exam of facial bones, complete, minimum of 3 views. Use it for plain-film follow-up of healing.
• 20680: Removal of implant, deep (e.g., buried wire, pin, screw, plate). It may apply for planned hardware removal; check global-period rules.

---

🏷️ Modifier Reference

Modifier	Name	When to Apply
-24	Unrelated E/M	Use when the surgeon bills an E/M during the global period for a problem unrelated to the fracture repair. Do not use it for routine fracture follow-up.
-25	Significant E/M	Use when a significant, separately identifiable E/M is performed on the same day as a minor procedure. Documentation must stand apart from the pre-procedure work.
-51	Multiple Procedures	Use on lower-valued procedures when several are performed in the same session, unless the code is modifier-51 exempt.
-58	Staged	Use for a planned or staged related procedure by the same physician during the global period, such as planned hardware removal.
-59	Distinct Service	Use to show a separate site or session when NCCI would otherwise bundle the codes, and only when documentation supports it.
-78	Return to OR	Use for an unplanned related return to the OR during the global period, such as for a complication.
-79	Unrelated Procedure	Use for an unrelated procedure during the postoperative period of a different surgery.

---

NCCI Bundling Considerations

Postoperative follow-up by the operating surgeon is included in the global package of the repair code (21432 carries a 90-day global), so routine visits are not separately billable. Check current NCCI PTP edits before reporting imaging or hardware removal with related repairs.

---

🔬 ICD-10-PCS Crosswalk

ICD-10 CM S02.413D is a follow-up diagnosis and has no direct PCS match. These are root-operation tables only, so select the full 7-character code from the current FY2026 PCS tables.

• 0NS (Reposition, Head and Facial Bones): Used for open or closed reduction of the original fracture, typically at the initial encounter.
• 0NH (Insertion, Head and Facial Bones): Used when plates, screws, or fixation devices are placed during repair.
• 0NP (Removal, Head and Facial Bones): Used for later removal of fixation hardware.
• 0NW (Revision, Head and Facial Bones): Used if hardware or fixation is adjusted or corrected.

---

💊 Coding Scenarios and Examples

Example 1

Clinical Scenario:
A patient is seen by the operating surgeon 3 weeks after open repair of a LeFort III fracture. Healing is progressing normally and there are no complications.

Field	Code	Rationale
CPT	99024	Postoperative visit within the 90-day global package of the repair, reported at no charge.
PDx	S02.413D	Follow-up of the LeFort III fracture with routine healing.

Tip

Use D because active treatment is complete and healing is routine. CDI: confirm “routine healing” is documented, because delayed healing would change the code to G.

Example 2

Clinical Scenario:
A provider outside the surgeon’s group evaluates a patient 8 weeks after LeFort III repair for follow-up and orders a maxillofacial CT to check alignment.

Field	Code	Rationale
CPT	99213	Established-patient office visit by a provider who is not under the surgeon’s global package.
CPT 2	70486	CT maxillofacial area without contrast to assess healing.
PDx	S02.413D	Follow-up of the LeFort III fracture with routine healing.

Tip

Link S02.413D to both the visit and the CT. Check A57215 for medical-necessity coverage on the imaging.⁴ CDI: document the clinical reason for imaging, such as assessing alignment or hardware position.

Example 3

Clinical Scenario:
The surgeon performs a planned removal of fixation hardware four months after LeFort III repair. The fracture has healed routinely.

Field	Code	Rationale
CPT	20680--58	Planned, staged related procedure by the same physician during the global period.
PDx	S02.413D	Subsequent care of the fracture with routine healing.

Tip

Documentation must show the removal was planned from the start. If it was unplanned, review -78 instead. CDI: note the reason for removal, such as planned removal versus symptomatic hardware.

---

⚠️ Coding Pitfalls and Tips

• Pitfall 1: Reporting S02.413A at a follow-up visit after active treatment is done; Tips: Use D for routine healing visits after treatment.
• Pitfall 2: Choosing S02.92XD when the LeFort type is documented in the record; Tips: Read the op note and imaging reports, and query when the type is unclear.
• Pitfall 3: Using D when the provider documents delayed healing or nonunion; Tips: Use S02.413G or S02.413K based on the documented healing status.
• Pitfall 4: Billing separate E/M visits for routine postoperative care during the global period; Tips: Report 99024 and use -24 only for unrelated problems.
• Pitfall 5: Missing associated injuries such as brain, eye, or cranial nerve injury; Tips: Follow the “code also” instruction at S02 and code documented injuries.
• Pitfall 6: Assuming A57215 covers your region for imaging; Tips: Check your MAC’s current article and LCD before billing.⁴

---

📚 Sources

1. ICD10Data.com. *2026 ICD-10-CM Diagnosis Code S02.413D.* https://www.icd10data.com/ICD10CM/Codes/S00-T88/S00-S09/S02/S02.4-/S02.413D 2. ICD List. *S02.413D ICD-10: LeFort III fracture.* https://icdlist.com/icd-10/S02.413D 3. Centers for Medicare & Medicaid Services. *ICD-10-CM/PCS MS-DRG v40.0 Definitions Manual, MDC 08.* https://www.cms.gov/icd10m/version40-fullcode-cms/fullcode_cms/P0551.html 4. CMS Medicare Coverage Database. *MRI and CT Scans of the Head and Neck (A57215).* https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57215&ver=41 5. American Academy of Otolaryngology-Head and Neck Surgery. *Clinical Indicators: Le Fort Fracture.* https://www.entnet.org/resource/clinical-indicators-le-fort-fracture/ 6. ICD10Data.com. *S02.4 Fracture of malar, maxillary and zygoma bones.* https://www.icd10data.com/ICD10CM/Codes/S00-T88/S00-S09/S02/S02.4-

_{Sources listed above correspond to superscript citations throughout this note. Verify all Medicare payment figures against your current CMS PFS Lookup tool and applicable MAC LCD prior to claim submission. Please use the latest AAPC/AHIMA Coding Books to verify each code within this note.}