# Need help !!



## prem_ponnuru (Jun 30, 2009)

*Need information !!*

Hi all,

Can anybody explain me, is it possible to perform closed reduction if the fracture is open fracture.

Need help !!

Thanks in advance.

Prem.


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## martnel (Jun 30, 2009)

Yes!  An open fracture means the skin is disrupted, closed fx, skin is intact.  A closed reduction means no incision is made.  Open reduction, they incise the skin.  So... with a closed reduction for an open fracture it means that it was already open prior to the reduction, and no further incisions are made, the Doc will do the same as if the skin was intact.  I hope that helps?


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## prem_ponnuru (Jul 1, 2009)

Hi,

Thanks for your response.

when I checked encoder medical necessity is not passing for closed reduction with open fractures. 

 can you please explain me this ?


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## martnel (Jul 2, 2009)

Which anatomical site is involved?  I checked the Orthopedic Coding Companion (Ingenix) and saw that some sites are cross referencing and others not.


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## prem_ponnuru (Jul 7, 2009)

Hi,

I just want to confirm.

I checked  cross coder for  closed treatment and did not find open fracture for any site. For open treatment for every site open fractures are listed.

Prem.


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## Anna Weaver (Jul 7, 2009)

*help fracture*

There was just an article in Part B insider on this very question. Date was June 15 Vol. 10 #21. 

READER QUESTION :Open Fracture May Not Require Use of Open Fracture Care Codes


Keep an eye on the full operative report -- not just the diagnosis codes -- to determine fracture care type.

Question: Our orthopedic surgeon documented fracture care for an open scapula fracture, and our coder automatically assigned the open fracture care code, but I didn't think open fractures always required open treatment. Who is right?

Answer: An open fracture (also referred to as a “compound fracture”) occurs when a patient breaks his bone and the skin and has an open wound down to the fracture site.

For such a fracture to the scapula, for example, you'd report 811.1x (Fracture of scapula; open) to describe the injury.

Many coders mistakenly assume that open fractures always require open treatment, in which the physician makes a surgical incision to treat the fracture.

If the orthopedic surgeon performs open fracture care at the scapula, you should report 23585 (Open treatment of scapular fracture [body, glenoid or acromion] includes internal fixation, when performed). But you should not assume that this code is accurate just because the physician documented an open fracture.

Physicians can address open fractures using closed fracture treatment as well. Closed treatment can include casting, strapping, and splinting.

If your physician tells you that he performed closed fracture care of the scapula, you should report 23570 (Closed treatment of scapular fracture; without manipulation) or 23575 (... with manipulation, with or without skeletal traction [with or without shoulder joint involvement]).

If the physician does not specify in the report whether he performed open or closed treatment, you should ask him which service he performed rather than simply assuming that he performed open treatment. Ninetynine percent of the time, the physician does -- but don't be caught offguard by that one percent.


See if this helps you?


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## abbycat333 (Apr 6, 2012)

*Other methods of treating open fractures*

I might be able to help re: open fractures and closed treatment. Often an open fracture is initially treated with an external fixator to stabilize the fragments and closed reduction is performed (manipulation), with just a washout or debridement of the open wound site. You can code this with the appropriate external fixation code, for example, uniplane 20690, then the closed reduction code, for example 27825, and then code the fracture debridement, using a code that describes the deepest level tissue that was removed. Sometimes the fracture will heal with no open treatment after this, and eventually the fixator can be removed, and the wound treated until it heals. Or, the physician may plan to place internal fixation and you would use the ORIF code, with modifier 58, because this would be a staged procedure. If an IM nail is placed instead of a plate type of fixation, then you would use the appropriate closed treatment, IM nail fixation code. You can report debridement of the site of the open fracture separately with modifier 59, since the IM nail is inserted at a location on the body that is different than the open fracture wound.
Many closed fractures require open treatment, and many open fractures can be treated with manipulation or stabilization without needing any incision. CPT codes for open fracture treatment used to all be "Open reduction, internal fixation" but new techniques to surgically manage open fractures made the AMA change to "Open treatment" which will have in the descriptor, "with internal fixation, when performed". 
Also, I might mention that open or closed fractures can be treated with percutaneous fixation. Percu fixation will tend to mention the use of fluoroscopy to guide pin placement into the fragments, and you usually see very small incisions just to admit the K-wire or screw or small plate. No debridement of an open fracture will be done. With open treatment, the op note will say the fracture was manipulated "under direct vision" and this may be either through the open fracture wound, or through an additional incision to approach the fracture site. 
I am not able to explain why closed treatment with or without manipulation codes are paired with only closed fracture diagnosis codes in most coding books and software.


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## abbycat333 (Apr 6, 2012)

*Further thoughts on open fracture treatment.*

Martnel, you indicated that with open treatment of a fracture, surgeons always make in incision. This is not always true. An open fracture wound can be utilized by surgeons to fix the fracture. If this is the case, you would by the way, not separately report the debridement of the wound, the 11010 to 11012 range of codes. If a separate incision is created to access the open fracture, and the fracture wound is debrided, then you may use the debridement code. Another type of open fracture is one which has no break in the skin caused by the broken end of a bone sticking through the skin (also called a compound fracture). It is when the sharp fragment of a fracture causes a wound in any body orifice or organ which opens to the air. An example could be: a pubic ramus fracture in which the sharp bone perforates the bladder, which opens to the outside of the body. Or, if a broken mandible perforates the cheek, or floor of the mouth, which opens to the outside of the body. Obviously, the broken pubic ramus fracture can be treated closed, and so can the broken jaw be managed closed.
There is no easy formula for determining which fracture codes to use. You must read the op note and understand in depth what was done and why it was done. You must understand not only anatomy, but surgical technique, approaches, and reasoning. If you are not willing to ask your doc lots of questions and read lots, then perhaps you are not adequately committed to coding. I don't mean to be harsh, but this is the reality.


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