June 19, 2012

ICD-10-CM Coding of Physeal Fractures Using the Salter-Harris Classification System

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Physeal fractures, also referred to as growth plate fractures, are fractures that occur in the distal or proximal physis of the long bones, and they are of particular concern when they occur in children and adolescents who have not finished growing. Until full growth is attained, the growth plates are open and filled with cartilaginous tissue. When a physeal fracture occurs, the cartilaginous tissue of the growth plate becomes disrupted or separated, and when this occurs, bone growth may be affected.

In the United States, physeal fractures are classified by severity using a system developed in 1963 by Robert Salter and W. Robert Harris; the system is known as the Salter-Harris classification system.

Anatomy of Long Bones

To understand the Salter-Harris classification system, one must understand the anatomy of the long bones. A typical long bone is composed of the following parts:

Diaphysis: The diaphysis also is referred to as the shaft. This is the middle section of the long bone, and it is composed of compact bone tissue.

Epiphysis: Each long bone has two epiphyses, one located at the proximal end and one at the distal end. The epiphyses are composed of spongy bone that contains bone marrow.

Physis: The physis also is referred to as the growth plate, epiphyseal plate or epiphyseal cartilage. This is the cartilaginous region between the diaphysis and epiphysis, where bone growth occurs.

Periosteum: The dense, white, fibrous membrane that covers the external surface of the bone.

Some Salter-Harris fractures involve only the physis, while others extend into the epiphysis or diaphysis.

An overview of the Salter-Harris Classification System

Physeal fractures are classified into nine types using the Salter-Harris classification system. Types I-IV are the most common, and the characteristics of these four types are as follows:

Type I: Fracture of the bone through the growth plate with separation of the epiphysis from the diaphysis.

Type II: Fracture of the bone through the growth plate and a portion of the diaphysis without a fracture of the epiphysis.

Type III: Fracture through the growth plate and epiphysis with a complete break through the epiphysis.

Type IV: Fracture through the diaphysis, growth plate and epiphysis.

Types V-IX are less common types of physeal fractures, and have the following characteristics:

Type V: This is a crush- or compression-type injury that involves only the growth plate without a fracture of either the diaphysis or epiphysis.

Type VI: A rare injury involving perichondral structures. Perichondrium is the connective tissue membrane that surrounds cartilage.

Type VII: An isolated injury of the growth plate.

Type VIII: An isolated injury of the metaphysis with potential complications related to endochondral ossification. Endochondrium is intracartilaginous tissue.

Type IX: An injury to the periosteum with the potential to interfere with membranous growth.

Diagnosis Coding of Physeal Fractures

In ICD-9-CM, physeal fractures (like most other types of fractures) are reported by denoting the location of the fracture and whether the fracture is open or closed. So a physeal fracture of the distal femur would be reported as 821.22 for a closed fracture or 821.32 for an open fracture. It should be noted that these codes are not specific to Salter-Harris fractures. These codes are used for any fracture or separation of the epiphysis in the lower end of the femur. These codes are reported both for adults (who have closed growth plates) and children and adolescents (who have open growth plates) even though the potential for complications, including arrested bone growth, is much greater for children and adolescents.

 


 

In ICD-10-CM, physeal fractures are reported based on site, laterality, Salter-Harris classification, episode of care and, during the healing phase, whether the care is for routine or delayed healing or for a nonunion or malunion. There are 18 six-character codes available in ICD-10-CM for a physeal fracture of the distal femur, and each of these 18 codes requires a seventh-character extension to capture the episode of care. The seventh-character extensions include:

A       Initial encounter for closed 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

It should be noted that there is no seventh-character extension for an open physeal fracture, as Salter-Harris classifications relate to closed injuries of the physis.

The available six-character codes are as follows:

S79.101- Unspecified physeal fracture of lower end of right femur

S79.102- Unspecified physeal fracture of lower end of left femur

S79.109- Unspecified physeal fracture of lower end of unspecified femur

S79.111- Salter-Harris Type I physeal fracture of lower end of right femur

S79.112- Salter-Harris Type I physeal fracture of lower end of left femur

S79.119- Salter-Harris Type I physeal fracture of lower end of unspecified femur

S79.121- Salter-Harris Type II physeal fracture of lower end of right femur

S79.122- Salter-Harris Type II physeal fracture of lower end of left femur

S79.129- Salter-Harris Type II physeal fracture of lower end of unspecified femur

S79.131- Salter-Harris Type III physeal fracture of lower end of right femur

S79.132- Salter-Harris Type III physeal fracture of lower end of left femur

S79.139- Salter-Harris Type III physeal fracture of lower end of unspecified femur

S79.141- Salter-Harris Type IV physeal fracture of lower end of right femur

S79.142- Salter-Harris Type IV physeal fracture of lower end of left femur

S79.149- Salter-Harris Type IV physeal fracture of lower end of unspecified femur

S79.191- Other physeal fracture of lower end of right femur

S79.192- Other physeal fracture of lower end of left femur

S79.199- Other physeal fracture of lower end of unspecified femur

It should be noted that, in ICD-10-CM, there are codes for unspecified type and unspecified side of physeal fractures. However, these codes should be used rarely as documentation; in most instances, identification of the Salter-Harris classification will be possible, as well as the side affected. If the documentation does not include this information, the physician should be queried so that the most specific code can be assigned.

 


 

Comparison of ICD-9-CM and ICD-10-CM Coding of Physeal Fractures

Condition

ICD-9-CM Code/Description

ICD-10-CM Code/Description

Initial encounter, Salter-Harris Type II physeal fracture of distal right femur

821.22 Fracture, femur, closed, epiphysis, lower (separation)

S79.121A Salter-Harris Type II physeal fracture of lower end of right femur, initial encounter for closed fracture

Follow-up care, Salter-Harris Type III physeal fracture of distal left femur with nonunion

733.82 Nonunion of fracture

S79.132K Salter-Harris Type III physeal fracture of lower end of left femur, subsequent encounter for fracture with nonunion

Partial growth plate arrest of distal right femur following traumatic Salter-Harris type II fracture of distal femoral epiphysis, sustained 1 year ago

733.91 Arrest of bone development or growth

905.4 Late effect of fracture of lower extremities

M89.157 Partial physeal arrest, right distal femur

S79.121S Salter-Harris Type II physeal fracture of lower end of right femur, sequela

Summary

ICD-10-CM coding of physeal fractures will require more specific documentation by physicians and a better understanding of the pathophysiology of these types of fractures by coders. Most of this information already should be included in the documentation. However, it is recommended that coders start reviewing ICD-10-CM references to determine what additional documentation might be required for the types of conditions their physicians regularly treat so that any documentation deficiencies can be addressed and resolved prior to the implementation of ICD-10-CM.

About the Author

Lauri Gray, RHIT, CPC, has worked in the health information management field for 30 years. She began her career as a health records supervisor in a multi-specialty clinic. Following that she worked in the managed care industry as a contracting and coding specialist for a major HMO. Most recently she has worked as a clinical technical editor of coding and reimbursement print and electronic products. She has also taught medical coding at the College of Eastern Utah. Areas of expertise include: ICD-10-CM, ICD-10-PCS, ICD-9-CM diagnosis and procedure coding, physician coding and reimbursement, claims adjudication processes, third-party reimbursement, RBRVS and fee schedule development. She is a member of the American Academy of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA).

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