Health Information Management

Them's the breaks

HIM-HIPAA Insider, July 28, 2014

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Julie comes into the Fix ‘Em Up Clinic with a seriously broken arm. Her son Jay left his toy fire engine on the stairs and Julie tripped over it. She threw her arms out to brace her fall. And then snap. Not a good sound to hear. Even worse, she realized the bone was sticking out of her arm.

Dr. Setter examines Julie and orders x-rays to determine the specific types and locations of the fractures. Because Julie’s fractures are open, he immediately schedules her for surgery at the Stitch ‘Em Up Hospital.
When Dr. Setter gets the x-rays back, he determines that Julie suffered diaphyseal fractures involving the right radius and ulna. Hmm, I don’t think that’s enough information to get us to the correct ICD-10-CM codes.
Codes for fractures of the forearm live in category S52. And you’ll notice a lot of codes under S52. They are broken down into:
  • Ulna and radius
  • Specific part of the bone
  • Displaced and nondisplaced
  • Left and right
  • Type of fracture
However, none of them are for a diaphyseal fracture. Now what? Well, if we check our handy medical dictionary (in book form or online) we can find out that a diaphyseal fracture involves the shaft of a long bone.
We do have codes for fractures of the shaft of the ulna and the radius—many, many codes. So it looks like we’re going to have to query Dr. Setter, unless of course our radiologist documented the details we need.
When we check the radiologist’s report, we find documentation of a displaced transverse fracture of the shaft of the right ulna and a displaced comminuted fracture of the shaft of the right radius. Because Dr. Setter documented the fractures, we can pull additional details from the radiologist’s report.
Dr. Setter also noted this is Julie’s first visit, so we would report codes:
  • S52.221B for the ulna fracture
  • S52.351B for the radius fracture
One thing we don’t have is the extent of the soft tissue damage on the Gustilo-Anderson classification scale. We can query for it or just default to B (initial encounter for open fracture NOS) for our seventh character.
Given the seriousness of Julie’s fractures, Dr. Setter is admitting her to the Stitch ‘Em Up Hospital, where Dr. Breaker will perform surgery to stabilize the fractures.
Dr. Breaker documents an open reduction internal fixation (ORIF) of the right radius and right ulna. Be very careful with ORIF. Sometimes the physician calls it an ORIF, but actually reduces the bone (moves it back into place) before creating the incision to place the fixation device.
In Dr. Breaker’s notes, she documents making the incision prior to reducing the fractures. Note that we need to know this for both fractures. Because the radius and the ulna are separate body parts in ICD-10-PCS, we are going to report separate codes for them. It’s possible that one reduction was open and one was closed. Dr. Breaker documents the same procedure for both bones.
What root operation does ORIF fall under? Well, what is the intent of the procedure? Dr. Breaker is putting the pieces of the bone back into their normal position. Sounds a lot like Reposition (moving to its normal location, or other suitable location, all or a portion of a body part).
Now that we have our root operation (and our section, Medical and Surgical, and our body system, upper bones), we can head to table 0PS (that’s a zero at the beginning of the code, not a capital O—no capital O or I in ICD-10-PCS).
We know the body parts for our two codes: right radius (H) and right ulna (K). Now for the approach. Dr. Breaker documented an open approach, so our fifth character is 0.
Our sixth character is the device and our choices are:
  • 4, internal fixation device
  • 5, external fixation device
  • 6, internal fixation device, intramedullary
  • B, external fixation device, monoplanar
  • C, external fixation device, ring
  • D, external fixation device, hybrid
  • Z, no device
We can eliminate all but two of those choices very quickly because we know Dr. Breaker used an internal fixation device. We just need to know whether it is intramedullary. Remember to look at the device for each procedure separately. Each fracture gets its own code, so the devices may be different.
In this case, Dr. Breaker documents internal fixation device, but does not mention intramedullary. That makes our sixth character 4 for both codes. The seventh character is easy. We only have one choice—Z (no qualifier).
For Julie’s surgery we would report:
  • 0PSH04Z, reposition right radius with internal fixation device, open approach
  • 0PSK04Z, reposition right ulna with internal fixation device, open approach
When Julie comes back in for routine follow-up care, we will use the same main ICD-10-CM codes we used for the initial fractures, just with a different seventh character. That will help us track how well a specific treatment works for a specific injury and also let us keep track of how well Julie heals.
This article originally appeared on HCPro’s ICD-10 Trainer blog.


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