Health Information Management

Fracture coding in ICD-10-CM requires greater specificity

JustCoding News: Outpatient, May 16, 2012

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A 25-year-old woman presents to the ED for an initial visit for treatment of open displaced tibia and fibula fractures of the left leg. The injuries occurred in an automobile accident. In addition, she lost a significant amount of blood from her left leg.

Coders must know the following details to assign a correct ICD-10-CM code for this scenario:

  • Which leg and which specific bones were injured
  • Whether the fracture was open or closed
  • Whether the fracture was displaced
  • Whether this was an initial or subsequent visit

For open fractures, coders must also know what type of associated trauma the patient suffered. This information helps coders choose the appropriate character based on the Gustilo-Anderson classification system.

Type of fracture
Providers must document, in some form, whether the fracture is traumatic or pathologic.

A traumatic fracture is caused by some type of accident, fall, or other kind of force. For example, a traumatic fracture can occur after a car accident or when a person is struck with a heavy object.

A pathologic fracture is a broken bone caused by disease. In ICD-9-CM, coders must choose from only eight pathologic fracture codes. ICD-10-CM expands this code selection to more than 150 codes.

So how do coders tell the two types of fractures apart? Sometimes it's pretty obvious. For example, if a patient fractures his leg after falling off the roof while replacing the tiles, this is a clear example of a traumatic fracture.

However, if a patient leans over to pick up a glass and breaks a vertebra, this patient likely suffered a pathologic fracture, says Robert S. Gold, MD, CEO and cofounder of DCBA, Inc., an Atlanta-based consulting company. Leaning over generally does not produce enough force to break a healthy bone, he says.

Don’t assume a fracture is traumatic if a patient suffers a fall or trauma that results in a fracture, says Sandy Nicholson, MA, RHIA, vice president of health information services for DCBA. If the force from a fall or trauma is insufficient to break a healthy bone, the fracture is pathologic, Nicholson says.

Site of fracture
Coders must know the site of the fracture. This includes not only which bone is broken, but also the specific location of the fracture on that bone, Gold says. For example, a patient fractures his femur.

Coders should look for documentation of which part of the femur he fractured. A physician may perform different procedures depending on the site of the fracture.

In addition, some ICD-10-CM codes include wording such as "distal end" or "proximal end," coders should look for this information in the medical record.

For example, codes for fractures of the phalanx of the finger are divided into the proximal, medial, and distal phalanx. The codes are further divided by the specific finger fractured and whether the fracture is displaced or nondisplaced. So coders would report code S62.655A for an initial encounter for a patient with a nondisplaced fracture of middle phalanx of left ring finger.

If more than one site is involved, coders can report multiple site codes, says Nicholson.

For example, if a patient presents with fractures to multiple ribs, coders should choose from among these codes and add the appropriate seventh character:

  • S22.41x, multiple fractures of ribs, right side
  • S22.42x, multiple fractures of ribs, left side
  • S22.43x, multiple fractures of ribs, bilateral
  • S22.49x, multiple fractures of ribs, unspecified side

If no multiple site code is available, report separate codes for each fracture. For example, coders should report separate codes (with the appropriate seventh character extension) when a patient fractures his or her tibia and fibula. Note that the codes also include mention of the specific area of the bone that is broken. For example, if the physician documented the displaced transverse fracture of shaft of left tibia and displaced comminuted fracture of shaft of left fibula, coders should report:

  • S82.222, displaced transverse fracture of shaft of left tibia
  • S82.452, displaced comminuted fracture of shaft of left fibula

ICD-10-CM pathologic fractures
If a fracture is caused by disease, not trauma, it is classified as a pathologic fracture. Not all pathologic fractures are due to cancer. Unfortunately, most physicians don't call a fracture pathologic unless it is caused by a malignancy, Gold says.

As a result, insufficient documentation of pathologic fractures can be problematic for coders, says Nicholson. "It's up to the physician to document whether it is a pathologic fracture," she says.

If coders don't know whether the fracture is pathologic or traumatic, they won't be able to select the correct code or even the correct code series. The increased specificity of the codes and new documentation requirements in ICD-10-CM offer an opportunity to educate physicians about the importance of documenting whether fractures are pathologic, Gold says.

For example, physicians should document the following details for osteoporosis:

  • Whether the osteoporosis occurs with or without current pathologic fracture and history of pathologic fracture
  • The specific bone fractured and laterality, as appropriate
  • Whether the osteoporosis is age-related or due to some other specific cause (e.g., chronic steroid use or vitamin deficiency)

Osteoporosis and fracture coding
ICD-10-CM code category M80- (osteoporosis with current pathologic fracture) denotes fractures caused by osteoporosis. Coders should only report a code from the M80- series when a patient has a current pathologic fracture at the time of the encounter.

When coding for the fracture, select the code based on the site of the fracture, not the location of the osteoporosis, Nicholson says. Consider the following examples of codes that denote a pathologic fracture with osteoporosis:

  • M80.011, age-related osteoporosis with current pathologic fracture, right shoulder
  • M80.022, age-related osteoporosis with current pathologic fracture, left humerus
  • M80.041, age-related osteoporosis with current pathologic fracture, right hand
  • M80.871, other osteoporosis with current pathologic fracture, right ankle and foot

As with other pathologic fracture codes, those that denote pathologic fractures with osteoporosis include laterality. Some codes do offer options for unspecified laterality, such as unspecified shoulder, humerus, ankle, or foot.

Note that codes for pathologic fractures with ¬osteoporosis also require a seventh character to indicate episode of care.

Seventh character for closed fractures
The meaning of the seventh character for ICD-10-CM codes varies according to chapter and category.

Fracture codes are an example of a category of codes for which the seventh character includes additional information about the type of encounter.

When coding a closed fracture, coders must add one of the following seventh characters to each code:

  • A: Initial encounter for 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

Report seventh character A (initial encounter) while the patient is receiving active treatment for the injury. This includes:

  • Surgical treatment
  • ED encounter
  • Evaluation and treatment by a new physician

Extensions for subsequent encounter (i.e., D, G, K, and P) denote encounters after the patient has received active treatment of the injury and receives routine care for the injury during the healing or recovery phase. These types of encounters include:

  • Cast change or removal
  • Removal of external or internal fixation device
  • Medication adjustment
  • Other aftercare and follow-up visits

When a patient presents for a subsequent visit, physicians must document whether a fracture is considered routine or delayed healing, malunion, nonunion, or sequela. ICD-10-CM doesn't include an unspecified option for the seventh character extension, says Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, Mass.

Don't report the ICD-10-CM aftercare Z codes for aftercare for injuries. For aftercare of an injury, assign the acute injury code with the appropriate seventh character for subsequent encounter, McCall says.

Editor’s note: This article was originally published in the May issue of Briefings on APCs. Email your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at

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