April 21, 2014

No Bones about It: Fracture Coding in ICD-10 is a Challenge

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There are 17,045 codes in ICD-10-CM that relate to fractures. And 10,582 fracture codes are used simply to distinguish right versus left. In preparation for ICD-10, physician documentation must be assessed and gaps identified to ensure correct coding of your orthopedic encounters.

 

There are five fundamental criteria for ramping up fracture documentation:

  • Specific site of the fracture

  • Laterality

  • General characteristics of fracture type

  • Other specific characteristics

  • Seventh-digit extensions

According to the Coding Clinic published during the first quarter of 2013, coders can use X-ray reports to assign a code for specific site of the fracture once the provider has already diagnosed it. “If the X-ray report provides additional information regarding the site of a condition that the provider has already diagnosed,” the relevant section reads, “it would be appropriate to assign a code to identify the specificity that is documented in the x-ray report.”

This guidance certainly helps coders in ICD-10. However, additional training and documentation improvement for fractures is critically important. The following information provides an overview of each area mentioned above.

Specific Site of Fracture

The exact location of the fracture is required in ICD-10-CM. For example, when coding fractures of the clavicle, the proper code assignment will change depending on where the fracture is located, whether it is the sternal end (which also requires the identification of whether it is an anterior or posterior displaced fracture), shaft, or acromial/lateral end.

Laterality and General Characteristics

Identification of the injury as right or left side is also mandatory, along with the coding of each fracture’s general characteristics (displaced, non-displaced, open, or closed). Coder education and documentation improvement efforts should focus on all the various types of fractures and associated definitions (comminuted, greenstick, oblique, segmental, spiral, torus, transverse, etc.). These also vary based on what bone is fractured and the exact site of the fracture.

Fractures not indicated as displaced or non-displaced should be coded to displaced. Fractures not designated as open or closed should be coded as closed. And multiple fractures are sequenced in accordance with the severity of the fracture.

Chapter 19 also indicates that some fracture categories provide for a seventh character to designate the specific type of open fracture and any other information captured in the specific code description based on three different fracture classifications.

Fracture Classification Systems

There are three fracture classification systems specifically referenced in ICD-10. These include:

  • Neer classification for fracture of the proximal or upper end of the humerus

  • Gustilo classification for open fracture of the long bones

  • Salter-Harris classification for physeal fractures

Each of these warrants additional coder training and documentation granularity. For example, the Gustilo classification for open fracture of the long bones includes three different wound types and associated subtypes.

Seventh Characters

ICD-10 also includes seven seventh-digit extensions to designate the episode of care as initial, subsequent or sequela. Definitions for each of these are also spelled out in Chapter 19:

A – Initial closed fracture

B – Initial open fracture

D – Subsequent routine healing

G – Subsequent delayed healing

K – Subsequent nonunion

P – Subsequent malunion

S – Sequela

Got Bones? Get Coding.

Organizations with a significant number of fractures and orthopedic procedures must get started early with clinical documentation assessments, gap analysis and coder education. Include clinical documentation improvement (CDI) team members, as they bolster physician communication and can help you update physician queries for ICD-10.

Finally, focus on Chapter 19 and start practicing with actual cases. There’s no time like the present!

Kim Carr, RHIT, CCS, CDIP, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer

Kim Carr brings more than 30 years of health information and clinical documentation improvement management experience and expertise to her role as Director of Clinical Documentation, where she provides oversight for auditing and documentation improvement for HRS clients. Prior to joining HRS, Kim worked as a consultant implementing CDI programs in varied environments such as level-one trauma centers, small community hospitals and all levels in between.

Before joining the consultant arena, Kim served as Manager of CDI in an academic level-one trauma center. She was responsible for education and training for physicians and clinical documentation specialists. Over the past 30 years, Kim has held several HIM positions; including HIM Coding Educator, Quality Assurance/Utilization Management Coordinator, DRG Coding Coordinator and Coding Manager. Kim holds a degree in Health Information Management and is a member of AHIMA, THIMA, ACDIS and AAPC.