Health Information Management

Tip: Look for specific fracture sites when assigning ICD-10-CM codes

APCs Insider, May 18, 2012

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Coders will need more detailed information to assign ICD-10-CM fractures.

Coders will need to know the specific fracture site. This includes the specific bone and specific location of the bone fracture, For example, a patient suffers a fractured femur. Coders should look for documentation that indicates which part of the femur is fractured. A physician may perform different procedures depending on the site of a fracture.

Some ICD-10-CM codes will include terms such as distal end or proximal end; coders should look for this information in the medical record. Codes for fractures of the phalanx of the finger are categorized as proximal, medial, and distal phalanx.

The codes provide even greater detail by denoting specific fingers and whether fractures are displaced or nondisplaced. Report code S62.655A for an initial patient encounter for a nondisplaced fracture of the middle phalanx of the left ring finger.

Coders may report multiple side codes when more than one site is involved. 

The tip is adapted from “Fracture coding in ICD-10-CM requires greater specificity” in the May Briefings on APCs.

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