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Medical and surgical orthopedic coding

Staff Development Weekly: Insight on Evidence-Based Practice in Education, June 3, 2005

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A 78-year-old female regularly ambulates with a walker. One day she falls for no apparent reason. She goes to the emergency department for evaluation. A physician diagnoses her with a hip fracture as a result of the fall. However, the radiological findings also indicate that her bones are fragile and porous, which indicated osteoporosis. She is admitted to the hospital where she is stabilized and treated with conservative care and immobilization. This is a pathological type fracture, which is defined as a type of fracture occurring because of a bone disease, so the bone disease (osteoporosis) and the condition (hip fracture) must both be coded.

Code the diagnostic code and indicate the diagnostic-related group (DRG).

Answer: ICD-9 820.01 for the fracture; 733.01 for the osteoporosis - DRG is 236

It is important in orthopedic coding to determine the exact treatment. Is a fracture treated as open or closed? Is there a repair or a revision? Carefully read the medical record documentation to make these important determinations. At times, surgical procedures may utilize different approaches, such as arthroscopes, and multiple procedures may be performed at the same time.

Editor's note: The above excerpt is from the new online course, "Inpatient Coding Module: Medical and surgical orthopedic coding." For more information on this and other courses in our Coding library, go to www.hcprofessor.com and click on Coding/Reimbursement.

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