Health Information Management

Q&A: Coding conflicting documentation

HIM-HIPAA Insider, July 12, 2011

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Q: Many of our orthopedic surgeons are documenting open reduction internal fixation (ORIF); however, when we read the body of the operative report, it’s clear that they actually performed a closed reduction before opening the patient. In some instances, they didn’t perform a reduction at all. We have started to query the surgeons about this issue and wondered how other facilities are handling this.

A: Coders should always read operative reports fully and then code according to the specific physician documentation found in the report. The ICD-9-CM index specifies the following:
Fracture (closed) 79.00
With internal fixation 79.10
Keep the following other points in mind:
  • If the surgeon reduces the fracture prior to incision and internal fixation, this is considered a closed fracture reduction with internal fixation. Report ICD-9-CM procedure code 79.10.
  • Open fracture reductions are those that surgeons perform after making an incision into the fracture site. Report ICD-9-CM procedure code 79.30 when the physician also performs internal fixation.
  • Coders should pay attention to the Multiple Coding Clinic references regarding closed reductions with internal fixations. These include Coding Clinic, First Quarter 1993, p. 27; Coding Clinic, Fourth Quarter 1993, p. 35; and Coding Clinic, Second Quarter 1994, p. 6. In addition, see Coding Clinic, Second Quarter 1993, p. 3, for additional guidelines regarding types of fracture treatment.
  • If the surgeon performs internal fixation without any fracture reduction, report ICD-9-CM procedure code 78.5x. The ICD-9-CM index specifies the following:
Internal (without fracture reduction) 78.50
With fracture reduction—see Reduction, fracture
Editor’s note: Jean Stone, RHIT, CCS, coding manager at Lucile Packard Children’s Hospital at Stanford in Palo Alto, CA, answered this question in the July issue of Briefings on Coding Compliance Strategies.

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