January 29, 2013

Gustilo Classification - Another Classification System for Coders to Understand

By

Codes in the ICD-9-CM classification system to report fracture aftercare are limited. The ICD-9-CM Official Guidelines indicate that the facility that provides the initial fracture treatment reports a code for the acute fracture.

Rehabilitation facilities that provide subsequent care for healing fractures must report codes for fracture aftercare, as the initial fracture care has already been provided. Codes that report the initial fracture treatment include information about the bone and the specific part of the bone where the fracture occurred and if the fracture was open or closed, displaced or non-displaced, and other specific information about the fracture. Currently, the rehabilitation facility reports fracture aftercare codes that show the fracture is healing, traumatic, or pathologic and the general site of the fracture, e.g. hip, vertebrae, upper extremity, etc. The information about the fracture provided by the acute fracture codes is not included in the aftercare codes. This will change with the implementation of ICD-10-CM.

ICD-10-CM includes codes specific to the site of fracture and includes a seventh character to report additional information about the fracture. The category codes and subcategory codes assigned for the initial treatment and subsequent treatment are the same. The seventh character indicates if the encounter is for the initial fracture treatment or a subsequent encounter. The seventh character also reports if the fracture is open or closed, and other detailed information about the fracture.

Coders that assign codes for both facilities that provide the initial treatment of open fractures and those that provide subsequent care for open fractures (rehabilitation hospitals, long-term care hospitals, nursing facilities, etc.) will need to understand the Gustilo classification system for assignment of the seventh character. The Gustilo classification system classifies open fractures based on the amount of energy, extent of soft tissue injury, extent of contamination, or arterial injury to determine the severity of the fracture. Grade I is the least severe, with Grade III the more severe open fractures.

Gustilo Open Fracture Classification

Type

Description

I

Clean wound, wound less than 1 cm, minimal soft tissue injury

II

Wound greater than 1 cm, moderate soft tissue injury

III

Extensive damage to soft tissues, including muscle, skin, and neurovascular structures; includes

  • Traumatic amputations
  • Fractures over 8 hours old
  • Fractures requiring vascular repair
  • Farm injuries with soil contamination

IIIA

Type III with adequate soft tissue coverage of fractured bone despite extensive soft tissue laceration or damage

Includes severely comminuted fractures

IIIB

Type III with extensive soft tissue lost with periosteal stripping and bony exposure

Usually associated with massive contamination

IIIC

Type III with arterial injury requiring repair

ICD-10-CM includes a seventh character (B, C, E, F, H, J, M, N, Q, or R) to identify open fractures with the Gustilo classification. These are available to use with categories S52: fracture of forearm, S72: fracture of femur, and S82: fracture of lower leg, including ankle.


The following seventh characters are available to report with codes for open fractures in categories S52, S72, and S82:

B     Initial encounter for open fracture type I or II

Initial encounter for open fracture NOS

C     Initial encounter for open fracture type IIIA, IIIB, or IIIC

E     Subsequent encounter for open fracture type I or II with routine healing

F     Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing

H     Subsequent encounter for open fracture type I or II with delayed healing

J      Subsequent encounter for open fracture IIIA, IIIB, or IIIC with delayed healing

M    Subsequent encounter for open fracture type I or II with nonunion

N     Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion

Q     Subsequent encounter for open fracture type I or II with malunion

R     Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

Example: Encounter for occupational therapy for open nondisplaced fracture neck of right radius, with extensive soft tissue injury with routine healing.        Code: S52.134F

About the Author

Patricia Trela, RHIA, is the director of HIM and rehabilitation services for Diskriter, Inc., a consulting firm offering integrated HIM rehabilitation consulting services, including HIM Interim management, IRF PPS compliance and education, coding and auditing support, dictation/transcription, and other solutions. She has more than 25 years of healthcare industry experience.  As a consultant, Pat has worked with many acute-care hospitals, rehabilitation hospitals and long-term acute-care hospitals (LTACH).  Pat facilitates the AHIMA Coding Physical Medicine Rehabilitation Community of Practice (COP).

Contact the Author

To comment on this article please go to