Is S42.495G a billable ICD-10-CM code?

Yes. S42.495G is a billable, specific ICD-10-CM code and is valid for submission on a claim.

Where does S42.495G sit in the tabular list?

Injury, poisoning and certain other consequences of external causes (S00-T88), in the block Injuries to the shoulder and upper arm (S40-S49).

What cannot be coded together with S42.495G?

S42.495G carries Excludes1 notes, which means the conditions they list can never be coded together with it on the same encounter. Some are written on the categories above S42.495G (S42) and apply to it just the same.

S42.495G

S42.495G — Other nondisplaced fracture of lower end of left humerus, subsequent encounter for fracture with delayed healing

Billable / specific codeICD-10-CMPOA exemptleft

S42.495G is a billable, specific ICD-10-CM code for other nondisplaced fracture of lower end of left humerus, subsequent encounter for fracture with delayed healing. It is valid for submission on a claim.

7th character "G" — subsequent encounter for fracture with delayed healing

The appropriate 7th character is to be added to all codes from category S42

A: initial encounter for closed fracture
B: initial encounter for open fracture
D: subsequent encounter for fracture with routine healing
G: subsequent encounter for fracture with delayed healing
K: subsequent encounter for fracture with nonunion
P: subsequent encounter for fracture with malunion
S: sequela

Excludes1 inherited from the categories above S42.495G

These are not written on S42.495G, but they bind it: a note on a category applies to every code beneath it. Billing S42.495G with anything listed here is a denial.

Written on S42 — Fracture of shoulder and upper arm

traumatic amputation of shoulder and upper arm (S48.-)

Excludes2 inherited from the categories above S42.495G

Also inherited, and the opposite of Excludes1: these conditions are not part of S42.495G, but a patient can have both, so you may code both.

Written on S42.4 — Fracture of lower end of humerus

fracture of shaft of humerus (S42.3-)
physeal fracture of lower end of humerus (S49.1-)

Written on S42 — Fracture of shoulder and upper arm

periprosthetic fracture around internal prosthetic shoulder joint (M97.3)

Other codes that can never be billed with S42.495G

These codes carry an Excludes1 note pointing at S42.495G. The conflict binds both ways, but ICD-10-CM only writes it down on one side — so you would not find this by reading S42.495G alone.

M84.3Stress fracture
M84.4Pathological fracture, not elsewhere classified

Risk adjustment

S42.495G does not map to an HCC and does not risk-adjust under CMS-HCC V28. That is normal — most ICD-10 codes do not. It still needs to be coded correctly; it just will not move a RAF score.

Medicare coverage

S42.495G is named in 2 Medicare coverage policies — 2 listing it as supporting medical necessity. Which of them applies to you depends on your Medicare contractor, and coverage genuinely differs by state.

A53058Billing and Coding: Home Health Physical Therapy
A53065Billing and Coding: Outpatient Physical Therapy

Code history

S42.495G has not changed since FY2024 — no addition, revision or deletion across the three most recent ICD-10-CM releases.

Related codes at this level

Codes that share S42.495. If S42.495G is not quite right, the correct code is usually one of these.

Questions about S42.495G

Is S42.495G a billable ICD-10-CM code?: Yes. S42.495G is a billable, specific ICD-10-CM code and is valid for submission on a claim.
Where does S42.495G sit in the tabular list?: Injury, poisoning and certain other consequences of external causes (S00-T88), in the block Injuries to the shoulder and upper arm (S40-S49).
What cannot be coded together with S42.495G?: S42.495G carries Excludes1 notes, which means the conditions they list can never be coded together with it on the same encounter. Some are written on the categories above S42.495G (S42) and apply to it just the same.