Health Information Management

More documentation needed for fractures in ICD-10-CM

JustCoding News: Inpatient, June 6, 2012

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By now, you may have heard that the ICD-10-CM codes are more specific than those used in the ICD-9-CM system. The more specific codes don’t just give coders more options when coding a patient’s record. They provide a more complete clinical picture of the diagnoses a patient may have after being evaluated by a healthcare facility. However, if the physician documentation isn’t specific enough, coders will struggle to determine which codes to report.

During The JustCoding Virtual Summit: ICD-10-CM and ICD-10-PCS March 1, Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CPC-I, CCDS, director of HIM and coding at HCPro, Inc., in Danvers, Mass., led a session that highlighted the top coding documentation challenges in ICD-10-CM. In this article, we will take a look at some of the documentation challenges associated coding fractures in ICD-10-CM

Injury organization
The first major difference between fracture codes in ICD-10-CM and ICD-9-CM is the way the codes are organized.

ICD-9-CM classifies the codes first by the type of injury, then the anatomical site. However, ICD-10-CM organizes the codes by the anatomical site first and then the type of injury.

For example, in ICD-10-CM the code series S00-S09 includes the codes for injuries to the head. The S00-S09 series includes codes for superficial wounds, contusions, open wounds, fractures, dislocations, etc. This means all the codes reported for injuries to the head are in the sequential code category list, which “makes more logical sense when it comes to finding codes,” McCall said.

Default fracture types
Some of the fracture code series give coders an option of displaced or non-displaced. According to the ICD-10-CM Official Guidelines for Coding and Reporting, unless the documentation specifically states that the fracture was non-displaced, coders should assume it is displaced. Not everyone agrees with this guideline, McCall said, as most fractures are non-displaced. Regardless, coders must follow this rule unless the guideline changes at some point in the future, McCall said.

Similarly, when the physician does not specifically document a fracture as open or closed, coders are instructed to code the fracture as closed. This was also a rule in the ICD-9-CM, “so that isn’t anything new to learn,” McCall said.

Gustilo-Anderson fractures
Codes for fractures to the forearm (S52-), femur (S72-), and lower leg (S82-), use the Gustilo-Anderson classification for assigning the seventh characters for open fractures. “The utilization of this particular classification of fractures helps identify in greater detail the severity of those open fractures associated with particular body sites,” McCall said. Because the Gustilo-Anderson allows for greater detail, the physician may need to provide more detailed documentation to support code assignment.

The Gustilo-Anderson classification groups open fractures into three types:

  • Type I: The wound is smaller than 1 cm, clean, and generally caused by a fracture fragment that pierces the skin.
  • Type II: The wound is longer than 1 cm, not contaminated, and without major soft tissue damage or defect.
  • Type III: The wound is longer than 1 cm, with significant soft tissue disruption. The mechanism often involves high-energy trauma, resulting in a severely unstable fracture with varying degrees of fragmentation.

“Notice that as we look at the descriptions of these fractures the wound is getting bigger and a little more complicated,” McCall said. Indeed, a type III fracture is the most severe, but the classifications do not stop there. Type III fractures are further subdivided into three additional groups:

  • IIIA: The wound has sufficient soft tissue to cover the bone without the need for local or distant flap coverage.
  • IIIB: Disruption of the soft tissue is extensive, such that local or distant flap coverage is necessary to cover the bone. The wound may be contaminated, and serial irrigation and debridement procedures are necessary to ensure a clean surgical wound.
  • IIIC: Any open fracture associated with an arterial injury that requires repair is considered type IIIC. Involvement of vascular surgeons is generally required.

When coding an initial encounter for a type of fracture that uses the Gustilo-Anderson classification, the options for the seventh character are the following:

  • A: initial encounter for closed fracture
  • B: initial encounter for open fracture type I or II, or open fracture NOS
  • C: initial encounter for open fracture type IIIA, IIIB, or IIIC

Coders should be careful when assigning the seventh character because the letters do not correspond to the type IIIA, IIIB, and IIIC used in the Gustilo-Anderson classification discussed earlier. “That’s a little confusing,” McCall pointed out.

When looking at the first two options, A and B, coders will see that they differentiate between an open or closed fracture. Choosing a code based on whether a fracture is open or closed is not a new concept for fracture coding, McCall said, as the same choices were available in ICD-9-CM.

However, coders will notice that option B includes additional language that specifies the type of open fracture. Coders choose B when a fracture is a type I, a type II, or not otherwise specified. That means an open fracture will default to option B, unless the physician documents a type III open fracture.
Coders will use C to report open fracture types IIIA, IIIB, and IIIC.

“Of course wanting the most specific documentation, it would be great if we could have the physician document the open fracture as IIIA, IIIB, or IIIC, but notice that as long as [the physician] calls it a type III fracture, it appears that it would likely be assigned a seventh character of C for an initial encounter,” McCall said.

She adds that it will be important for physicians to identify when a patient suffers a type III fracture for the categories that use Gustilo-Anderson. Luckily, orthopedic physicians typically classify fractures this way when considering treatment options, so it may not be easy for them to document it, McCall said.

Fracture example
A physician performs an initial encounter for a comminuted fracture of the shaft of the right femur caused by trauma. The appropriate code for this scenario is S72.351A, according to McCall.

When looking in the alphabetic index for fractures of the femur and shaft, coders may notice that additional descriptors identify the nature of the fracture. For example options specify if the fracture is comminuted, transverse, or spiral. In this case the fracture is comminuted.

The example also does not specify whether the fracture is displaced or non-displaced. However the coding guidelines instruct coders default to displaced in the absence of documentation.

The correct seventh character option is A, McCall said. Coders may notice that the example does not specify whether the fracture is closed or open. According to the coding guidelines, when the physician doesn’t specifically document open or closed, the default option is closed.

Email your questions to Senior Managing Editor Andrea Kraynak, CPC, at

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