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M97.3 vs S42.90XG

M97.3 (Periprosthetic fracture around internal prosthetic shoulder joint) compared with S42.90XG (Fracture of unspecified shoulder girdle, part unspecified, subsequent encounter for fracture with delayed healing), from the official CMS tabular data.

Summary

These codes can be reported together when both conditions are documented, because S42.90XG 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”; S42.90XG is “Fracture of unspecified shoulder girdle, part unspecified, subsequent encounter for fracture with delayed healing”. M97.3 is a non-billable header; S42.90XG is billable. M97.3 sits in M00-M99 — Diseases of the Musculoskeletal System and Connective Tissue (M00-M99); S42.90XG 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.S42.90XG 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. S42.90XG carries 1 Excludes1 note covering other codes; the side-by-side table quotes them.

Official rule

Is there an Excludes2 relationship?

Yes.S42.90XG’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 S42.90XG 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

S42.90XG
Fracture of unspecified shoulder girdle, part unspecified, subsequent encounter for fracture with delayed healing
↔
M97.3
Periprosthetic fracture around internal prosthetic shoulder joint

What we found

Yes, when both are documented.S42.90XG 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 FY2026

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

M97.3Periprosthetic fracture around internal prosthetic shoulder jointS42.90XGFracture of unspecified shoulder girdle, part unspecified, subsequent encounter for fracture with delayed healing
Billing statusNon-billable header

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

Billable
ClassificationM00-M99 — Diseases of the Musculoskeletal System and Connective Tissue (M00-M99)S00-T88 — Injury, Poisoning and Certain Other Consequences of External Causes (S00-T88)
DefinitionPeriprosthetic fracture around internal prosthetic shoulder joint is a non-billable ICD-10-CM category code (M97.3).Fracture of unspecified shoulder girdle, part unspecified, subsequent encounter for fracture with delayed healing is a billable ICD-10-CM diagnosis code (S42.90XG).
7th characterThe appropriate 7th character is to be added to each code from category M97The appropriate 7th character is to be added to all codes from category S42
Includes—
injuries of axilla
injuries of scapular region
Excludes1—
traumatic amputation of shoulder and upper arm (S48.-)
Excludes2
fracture of bone following insertion of orthopedic implant, joint prosthesis or bone plate (M96.6-)
breakage (fracture) of prosthetic joint (T84.01-)
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 first
, if known, the specific type and cause of fracture, such as traumatic or pathological
—

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.

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Derived from the official CMS ICD-10-CM tabular data (FY2026). A coding-rule comparison, not billing advice: payer-specific edits and medical-necessity policy are outside its scope. All data sources