Updated on: January 29, 2014

Coding Fractures in ICD-10: The Right Code Means Everything

By Joseph J. Gurrieri, RHIA, CHP
Original story posted on: September 20, 2013

It’s no secret that ICD-10-CM offers more codes and increased granularity of data for the coding of orthopedic diagnosis and procedures. And it’s also no secret that orthopedic dollars are critical to a hospital’s bottom line—including revenue from treating fractures. Therefore, shoring up orthopedic documentation and coding is a critical step in your ICD-10 journey.

During the 2013 HIMSS ICD-10 Symposium, orthopedics was identified as one of the top-three specialty areas within healthcare most impacted by ICD-10. And at the recent HIMSS  Media ICD-10 Leadership Forum, fractures were recognized to require more detailed documentation and greater code specificity. All these speakers were right.

From the very first treatment encounter, ICD-10 requires specific, exact documentation for the coding of orthopedic encounters. But there is a silver lining, especially for fractures.

The Silver Lining

For decades healthcare organizations have asked for more detail regarding fractures. ICD-10 delivers it. ICD-10 CM affords us the ability to capture unique and specific data that includes:

  • Type of fracture – closed, open, displaced, nondisplaced
  • Specific anatomical site
  • Laterality
  • Routine versus delayed healing
  • Nonunion
  • Malunion
  • Type of encounter – initial, subsequent, sequela

Further detail may be required depending on the location of the fracture. Knowledge of the Gustilo-Grade Classification system for open fractures in addition to knowing the distinction in the types of Salter-Harris fractures will be essential for clinical documentation improvement (CDI) specialists and clinical coders alike.

A quick Google search on any of the terms listed below yields definitions for each. While not listed in the “official” coding guidelines, these definitions definitely contribute to CDI efforts and result in well-written physician queries. Since the ICD-10 code set specifies these definitions, the onus is on coders and CDI professionals to reference them.

Gustilo Grade

Definition

I

Open fracture, clean wound, wound <1 cm in length

II

Open fracture, wound > 1 cm in length without extensive soft-tissue damage, flaps, avulsions

III

Open fracture with extensive soft-tissue laceration, damage, or loss or an open segmental fracture. This type also includes open fractures caused by farm injuries, fractures requiring vascular repair, or fractures that have been open for 8 hr prior to treatment

IIIA

Type III fracture with adequate periosteal coverage of the fracture bone despite the extensive soft-tissue laceration or damage

IIIB

Type III fracture with extensive soft-tissue loss and periosteal stripping and bone damage. Usually associated with massive contamination. Will often need further soft-tissue coverage procedure (i.e. free or rotational flap)

IIIC

Type III fracture associated with an arterial injury requiring repair, irrespective of degree of soft-tissue injury

 


 

Salter-Harris Fracture

Type

Description

I

Transverse fracture through the growth plate

II

Fracture through the growth plate and the metaphysis, sparing the epiphysis

III

Fracture through the growth plate and epiphysis, sparing the metaphysis

IV

Fracture through all three elements of the bone, the growth plate, metaphysis, and epiphysis.

V

Compression fracture of the growth plate

VI

Injury to the peripheral portion of the physis and a resultant bony bridge formation which may produce an angular deformity

VII

Isolated injury of the epiphyseal plate

VIII

Isolate injury of the metaphysis with possible impairment of endochondral ossification

IX

Injury of the periosteum which may impair intramembranous ossification

Devil in the Details

Chapter 19 of the ICD-10 CM Official Coding Guidelines contains some very explicit guidelines for coders to follow when coding injuries, traumatic fractures and multiple fractures.

Coding of Injuries

When coding injuries, assign separate codes for each injury unless a combination code is provided, in which case the combination code is assigned. The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first.

Coding of Traumatic Fractures

The principles of multiple coding of injuries should be followed in coding fractures.  Fractures of specified sites are coded individually by site in accordance with both the provisions within categories S02, S12, S22, S32, S42, S49, S52, S59, S62, S72, S79, S82, S89, S92 and the level of detail furnished by medical record content. A fracture not indicated as open or closed should be coded to closed. A fracture not indicated whether displaced or nondisplaced should be coded to displaced.

Multiple Fractures Sequencing:

Multiple fractures are sequenced in accordance with the severity of the fracture.

 


 

So Many Bones, So Many Codes

Consider the following scenario to gain an understanding of just how detailed the fracture code set can become under ICD-10.

A 42 year-old female restrained passenger was involved in a motor vehicle accident. The car left the highway at high-speed after hitting a pothole and suffering mechanical failure. The Emergency Department record shows that the patient sustained a fracture of the first lumbar vertebra with a displaced bone fragment anterior to the vertebral column.

Under ICD-9-CM coding, this case would be coded as follows:

805  Fracture of vertebral column without mention of spinal cord injury

805.4 Lumbar, closed

 

Under ICD-10-CM, far more coding details are available to deliver greater specificity, more-exact reimbursement and stronger quality reporting.

S32  Fracture of lumbar spine and pelvis

S32.0  Fracture of lumbar vertebra

S32.01  Fracture first lumbar vertebra

S32.018  Other fracture first lumbar vertebra

Final Answer:   S32.018A Final digit indicates the initial encounter for treatment

 

With so many bones (the adult human has 206 bones) and so many codes left vs. right, subsequent vs. initial, routine vs. delayed, nonunion vs. malunion and more), everyone from clinicians to CDI specialists and coders must be on-board and up-to-speed way ahead of the October 1, 2014 deadline for ICD-10. Vague clinical documentation in orthopedic service lines will result in less revenue, foggy quality scores and poor follow-up care.

Simple process changes and coder education now can reap tremendous rewards later.

About the Author

Joseph Gurrieri serves as the vice president of HIM services and business development at H.I.M. ON CALL. He came to H.I.M. ON CALL in April 2006 from the New Jersey Hospital Association (NJHA) where he was the Assistant Vice President of Information Services. Joseph was awarded the Allied Health Profession Research Award by the SUNY Downstate Medical School for his outstanding research on managed care utilization in emergency departments. He was named the “1999 Preceptor of the Year” by the New York Health Information Management Association, after mentoring H.I.M. students through their internship program.

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.