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M97.3 vs S42.494B

M97.3 (Periprosthetic fracture around internal prosthetic shoulder joint) compared with S42.494B (Other nondisplaced fracture of lower end of right humerus, initial encounter for open fracture), from the official CMS tabular data.

Current data releases:ICD-10-CM FY2027 · ICD-10-PCS FY2027 · HCPCS October 2026 · MS-DRG v44 · Medicare Code Editor v44.0 · NCCI PTP Q4 2026 · MUE Q4 2026 · NCD code lists 2026-01 · LCD export September 28, 2026 · All releases and sources

Summary

These codes can be reported together when both conditions are documented, because S42.494B lists M97.3 under Excludes2, which marks them as distinct conditions.

Official rule
What is different?

The conditions named, billing status and chapter.M97.3 is “Periprosthetic fracture around internal prosthetic shoulder joint”; S42.494B is “Other nondisplaced fracture of lower end of right humerus, initial encounter for open fracture”. M97.3 is a non-billable header; S42.494B is billable. M97.3 sits in M00-M99 — Diseases of the Musculoskeletal System and Connective Tissue (M00-M99); S42.494B in S00-T88 — Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88).

Registry fact

Can these codes be reported together?

Yes, when both are documented.S42.494B lists M97.3 under Excludes2: “periprosthetic fracture around internal prosthetic shoulder joint (M97.3)”. Excludes2 marks distinct conditions that may both be reported when both are documented.

Official ruleGuide: Excludes1 vs Excludes2

Is there an Excludes1 relationship?

None.Neither entry carries an Excludes1 note that names the other code. S42.494B carries 1 Excludes1 note covering other codes; the side-by-side table quotes them.

Official rule

Is there an Excludes2 relationship?

Yes.S42.494B’s tabular entry: “periprosthetic fracture around internal prosthetic shoulder joint (M97.3)”. The note covers M97.3.

Official ruleGuide: Excludes1 vs Excludes2

Is one more specific?

Not comparable.The codes sit in different categories; specificity is only comparable within one category.

Is one a parent or header code?

One is a header.M97.3 is a non-billable header, but S42.494B is not one of its subdivisions.

Registry fact

Are there sequencing instructions?

None.Neither entry carries a Code First or Use Additional Code note that names the other.

Official rule

Are there other coding relationships?

None found.No laterality, encounter-phase, Table of Neoplasms, Table of Drugs and Chemicals, or history-versus-active-disease relationship links these codes.

MedCoder-derived

Official rule: a tabular instructional note or a section of the ICD-10-CM Official Guidelines, quoted as published. Registry fact: the codes’ own published attributes (titles, billable status, position in the hierarchy, code set). MedCoder-derived: a reading MedCoder computes from those facts; it is not itself a rule. How to read the labels

Can these codes be reported together?

Informational

Excludes2 relationship

S42.494B
Other nondisplaced fracture of lower end of right humerus, initial encounter for open fracture
↔
M97.3
Periprosthetic fracture around internal prosthetic shoulder joint

What we found

Yes, when both are documented.S42.494B carries an Excludes2 note covering M97.3: “periprosthetic fracture around internal prosthetic shoulder joint (M97.3)”

Excludes2 marks distinct conditions — both may be reported when both are documented.

What to review

Report both only when the documentation supports both conditions; otherwise report the one documented.

Guide: Excludes1 vs Excludes2Check these on a claim

Why it matters

An Excludes2 note means the excluded condition is not part of the code above it, but a patient can have both. Report both when both are documented.

Source / rule

CMS ICD-10-CM tabular instructional notes

Official guidance behind these answers

  • Section I.A.12.b — Excludes2 · applies to: Excludes2

    A type 2 Excludes note represents “Not included here.” An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

    ICD-10-CM Official Guidelines FY2027

Quoted from the ICD-10-CM Official Guidelines for Coding and Reporting in effect for the release shown. The tabular notes above are the code-level instruction; these sections are the convention that says how such a note is applied. Source document (CMS PDF) · Release and checksum

Side by side

Similar descriptions do not make codes interchangeable. The documentation and the official instructions decide which code applies.

Official descriptionDiffers
M97.3

Periprosthetic fracture around internal prosthetic shoulder joint

S42.494B

Other nondisplaced fracture of lower end of right humerus, initial encounter for open fracture

StatusDiffers
M97.3
Non-billable header

A header is not reported on a claim; a code beneath it is.

Report instead: M97.31XA, M97.31XD, M97.31XS, M97.32XA, M97.32XD

S42.494B
Billable
Excludes1Differs
M97.3

None at this code

S42.494B
  • traumatic amputation of shoulder and upper arm (S48.-)
Excludes2Differs
M97.3
  • fracture of bone following insertion of orthopedic implant, joint prosthesis or bone plate (M96.6-)
  • breakage (fracture) of prosthetic joint (T84.01-)
S42.494B
  • fracture of shaft of humerus (S42.3-)
  • physeal fracture of lower end of humerus (S49.1-)
  • periprosthetic fracture around internal prosthetic shoulder joint (M97.3)
  • burns and corrosions (T20-T32)
  • frostbite (T33-T34)
  • injuries of elbow (S50-S59)
  • insect bite or sting, venomous (T63.4)
Code firstDiffers
M97.3
  • , if known, the specific type and cause of fracture, such as traumatic or pathological
S42.494B

None at this code

CategoryDiffers
M97.3

M97 Periprosthetic fracture around internal prosthetic joint

S42.494B

S42 Fracture of shoulder and upper arm

ChapterDiffers
M97.3

M00-M99 — Diseases of the Musculoskeletal System and Connective Tissue (M00-M99)

S42.494B

S00-T88 — Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88)

IncludesDiffers
M97.3

None at this code

S42.494B
  • injuries of axilla
  • injuries of scapular region
7th characterDiffers
M97.3
  • The appropriate 7th character is to be added to each code from category M97
S42.494B
  • The appropriate 7th character is to be added to all codes from category S42

No Use additional code and Code also note at either code.

Notes are the code’s own tabular entry, quoted as published. A note that names the other code is the one the verdict above rests on. In a row that differs, notes every code shares are dimmed.

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Derived from the official CMS ICD-10-CM tabular data (FY2027). A coding-rule comparison, not billing advice: payer-specific edits and medical-necessity policy are outside its scope. All data sources