Health Information Management

Take the fear out of ICD-10-CM fracture coding

JustCoding News: Outpatient, January 25, 2012

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A 35-year-old man suffered open displaced tibia and fibula fractures of the right leg as the result of an automobile accident. In addition, he lost a lot of blood, also from the right leg.

To assign the correct ICD-10-CM code, coders will need to know:

  • Which leg and which specific bone(s) the patient injured (in this example, it’s the right tibia and fibula)
  • Whether the fracture is open or closed (in this case, open)
  • Whether the fracture is displaced (in this case, displaced)

For open fractures, coders will also need to know what type of associated trauma the patient suffered to choose the appropriate character based on the Gustilo-Anderson classification system.

But coders don’t need to despair, says Robert S. Gold, MD, CEO and cofounder of DCBA, Inc., an Atlanta-based consulting company. Most of that information is already in the medical record, even though it may be located in a variety of places. For example, some information may be in the ED record, while coders may have to read the nurses’ notes for other information.

Because that information is already in the record, the transition won’t be such a harrowing experience, Gold says. “We have virtually all of the information we need in the current medical record. You don’t have to worry about the physician learning something new.”

Gustilo-Anderson classifications
ICD-10-CM categories S52 (fracture of forearm), S72 (fracture of femur), and S82 (fracture of lower leg, including ankle) require additional seventh character extensions, says Shannon McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, director of HIM and coding at HCPro Inc., in Danvers, MA.
The seventh character identifies open fractures using the Gustilo-Anderson classifications, which are the most commonly used classifications for open fractures. The Gustilo-Anderson classification identifies the severity of the soft tissue damage.

Note the following Gustilo-Anderson classifications:

  • Type I: The wound is smaller than 1 cm, clean, and generally caused by a fracture fragment that pierces the skin (i.e., inside-out injury). This is the result of low-energy trauma, caused by things such as falls from a sitting or standing position.
  • Type II: The wound is longer than 1 cm, not contaminated, and without major soft tissue damage or defect. This is also a low-energy injury.
  • 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.

Type III fractures are further divided into

  • III A: Soft tissue coverage of the fractured bone is adequate.
  • III B: Extensive injury to or loss of soft tissue, with periosteal stripping and exposure of bone, massive contamination, and severe comminution of the fracture. After debridement and irrigation a local or free flap is necessary for coverage.
  • III C: Any open fracture that is associated with an arterial injury that a physician must repair, regardless of the degree of soft tissue injury.

Documentation should identify whether an open fracture is a type III, McCall says. Otherwise, coders should assign a seventh character B for the initial care of all other open fractures.
Fractures are indexed by type in the Alphabetical Index (pathologic vs. traumatic), but the index only will get you to the series of codes, McCall says.

Traumatic fractures
Coders will find a more extensive list of codes for traumatic fractures in ICD-10-CM, says Sandy Nicholson, MA, RHIA, vice president of Health Information Services for DCBA, Inc.

One thing coders will need to look for is the episode of care. Is this the patient’s first visit for treatment of this particular fracture or is he or she coming in for routine follow-up? Is the fracture healing correctly or did he or she suffer malunion of the bone?

When coding for a closed fracture, add the appropriate seventh character 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

Use the extension for initial encounter (A) while the patient is receiving active treatment for the injury, says McCall. Active treatment includes:

  • Surgical treatment
  • Emergency department encounter
  • Evaluation and treatment by a new physician

Extensions for subsequent encounter (i.e., D, G, K, and P) indicate encounters after the patient has received active treatment of the injury and is receiving 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

Coders should not use the Z series of codes to report aftercare of a fracture, Nicholson says. Z codes represent reasons for encounters. Instead, report the code for the actual fracture, such as S52.521 (torus fracture of lower end of right radius) with the appropriate seventh character.

Sequela are complications from the original injury. Again, report the code for the initial fracture with S as the seventh character.

Consider the following example. A patient suffered a spiral fracture of the shaft of the right femur six months ago. The fracture has healed nicely, but the patient is still experiencing pain in the right thigh.

For this scenario, report ICD-10-CM codes M79.651 (pain in right thigh) and S72.341S (displaced spiral fracture of shaft of right femur, sequela). Note: In ICD-10-CM, coders should report fractures not indicated as displaced or nondisplaced as displaced.

Site of the fracture
Coders will also need to know the site of the fracture, and that includes not just which bone is broken, but where on the bone the fracture is, Gold says. For example, a patient fractures his femur. Look for documentation of which part of the femur he fractured. A physician may perform different procedures depending on the site of the fracture.

Consider this sample of some possible codes for fractures of the femur:

  • S72.331, Displaced oblique fracture of shaft of right femur
  • S72.332, Displaced oblique fracture of shaft of left femur
  • S72.344, Nondisplaced spiral fracture of shaft of right femur
  • S72.345, Nondisplaced spiral fracture of shaft of left femur
  • S72.421, Displaced fracture of lateral condyle of right femur
  • S72.422, Displaced fracture of lateral condyle of left femur
  • S72.434, Nondisplaced fracture of medial condyle of right femur
  • S72.435, Nondisplaced fracture of medial condyle of left femur
  • S72.444, Nondisplaced fracture of lower epiphysis (separation) of right femur
  • S72.445, Nondisplaced fracture of lower epiphysis (separation) of left femur

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

For example, 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. For a patient with a nondisplaced fracture of middle phalanx of left ring finger, report code S62.655.

If more than one site is involved, coders can report multiple site codes, Nicholson says. If no multiple site code is available, report multiple codes.

Procedure coding for fractures
Some things won’t change after the switch to ICD-10-CM and that includes CPT® codes for physicians, Nicholson says. Surgeons will still bill using diagnosis and CPT codes.

Terminology also won’t change, nor will the importance of documentation, she says. Coders still need to read the operative report and code only what the physician actually performed. “We’re already familiar with this,” Nicholson says.

For example, a physician may say she performed an open reduction with internal fixation, but many times, the physician performs a closed reduction, then makes the incision to perform the internal fixation, Gold says. In this case, coders would report a closed reduction with internal fixation instead of the open reduction.

Many times the physician does not perform a reduction if the fragment is aligned well, Gold says. “Read the operative report to see what the physician really did.”

Editor’s note: E-mail questions to Senior Managing Editor Michelle Leppert, CPC-A, at Gold, Nicholson, and McCall will be part of the faculty for The JustCoding Virtual Summit: ICD-10-CM and ICD-10-PCS, February 29-March 2. This one-of-a-kind virtual summit offers practical, hands-on guidance for the challenges of ICD-10 preparation and implementation. You won’t have to budget for travel or brave uncertain weather to hear presentations from faculty and dialogue with these experts as well as your peers.


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