ICD-10-CM diagnosis code

S02.40DB Maxillary fracture, left side, initial encounter for open fracture

Billable: Yes, a complete code (FY2026)
Category: S02 Fracture of skull and facial bones
Chapter: 19. Injury, poisoning and certain other consequences of external causes

Encounter (7th character)

This code is for the initial encounter: the patient is receiving active treatment for the condition (for example surgery, an emergency department visit or evaluation by a new clinician).

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Other codes in S02

456 complete codes in this category.

All 456 codes in S02 →

Documentation tips

Make sure the note supports every element of the title, “Maxillary fracture, left side, initial encounter for open fracture”: each detail in it should be traceable to the history, examination or assessment.
Code to the highest specificity the documentation supports. If a detail is missing from the note, add it to the note rather than choosing a less specific code by default.
Check the Tabular List and official guidelines for instructional notes (“code first”, “use additional code”, Excludes1/Excludes2) that apply to S02.

The international WHO ICD-10 also has S02, with its inclusion and exclusion notes; titles and detail can differ from ICD-10-CM.

ICD-10-CM is developed by the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, and is based on the WHO ICD-10. Codes and titles are reproduced unchanged from the FY2026 code list (effective 1 October 2025). Their use here does not imply endorsement by CDC, HHS or the U.S. Government. Changes effective on or after 1 October 2026 may not be reflected yet; check the current release at cdc.gov or cms.gov before submitting claims.

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