# Code injury or osteoarthritis first?



## shegun4 (Mar 20, 2011)

This scenario has been a subject of contention, albeit friendly, in our office.  When a patient comes to hospital with the following:

HISORY:  MVA, injury, pain
PROCEDURE:  Left knee x-ray, 3 views 
DESCRIPTION:  Adult male presents to ER with pain in left knee following MVA.  Bone processes appear normal, slight swelling in soft tissues.  Degenerative joint desease noted.

IMPRESSION:  No acute abnormality, degenerative changes of left knee.

What should be coded first?  Some believe the injury, then the Ecode, then incidental findings of the DJD.  Others believe the DJD should be coded first, followed by the inury and Ecode.    We see this injury/disease scenario a lot in our radiology billing office, with maybe slightly different chronic dx's and Ecodes.  Please help us settle this ongoing disagreement.   Thanks!


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## mshinnbouck@gmail.com (Mar 20, 2011)

*Osteoarthritis & injury*

While not directly addressing this question, Coding Clinic 1993, fourth quarter gives us a coding paradigm.  In summary, the physician documentation must state if the injury is in accordance with the degree of trauma in order to connect any bone pathology findings to the injury. If not, you code the injury first, and then the underlying disease, followed by an E-code for the cause. 

Below is the coding clinic:

A pathologic fracture is defined as a break in a diseased bone due to weakening of the bone structure by pathologic processes (such as osteoporosis or bone tumors) without any identifiable trauma or following only minor trauma. Only the physician can make the determination that the fracture is out of proportion to the degree of trauma. X-ray indications of diseased bone may be used by the physician to arrive at a diagnosis of a pathologic fracture, but should not be used by coders to make this determination.

Fifth digits have been added to category 733.1, Pathologic fracture, to allow identification of the site of the fracture. Codes from 800-829 for traumatic fractures should never be used with a code from this category. External cause of injury codes (E-codes) may be used if the pathologic fracture follows minor trauma to identify the nature of this trauma. The new codes are as follows:

733.10 Pathologic fracture, unspecified site

733.11 Pathologic fracture of humerus

733.12 Pathologic fracture of distal radius and ulna Wrist NOS

733.13 Pathologic fracture of vertebrae Collapse of vertebra NOS

733.14 Pathologic fracture of neck of femur Hip NOS Femur NOS

733.15 Pathologic fracture of other specified part of femur

733.16 Pathologic fracture of tibia and fibula

733.19 Pathologic fracture of other specified site

Question:

After walking out of a nursing home and falling off the curb, an 89 year old woman, with a history of severe osteoporosis, is admitted to the hospital for a fractured left hip. X-rays show advanced osteoporosis, separation of the acetabulum, and crumbling fracture of head of the left femur. Should the fracture be coded as pathological or as the result of trauma?

Answer:

This is a clinical question that must be directed to the patient's physician. Sometimes minor trauma can cause a fracture in an individual with severely diseased bone, and that is called a pathological fracture. Only the physician can determine whether or not the level of injury is in accordance with the degree of trauma suffered by the patient.

If the physician determines that the fracture is due to trauma then only a code(s) from 800-829, Fractures, would be assigned. A code from category 733.0, Osteoporosis, may also be assigned. The pathological fracture code would not be assigned.

If, however, the physician determines that the fracture is pathological and due to osteoporosis, then code 733.14, Pathological fracture of neck of femur, and a code from category 733.0, Osteoporosis, should both be assigned. Code E888, Other and unspecified fall, may also be assigned.

© Copyright 1984-2006, American Hospital Association("AHA"), Chicago, Illinois. Reproduced with permission. No portion of this publication may be copied without the express, written consent of AHA.

Maria Shinn Bouck, CPC, CPMA, CHC
mshinnbouck@cohencpa.com


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## shegun4 (Mar 21, 2011)

Thank you, that was helpful.  Coding the fracture first is understood, but our concern is when there is no fracture, just stated "injury," e.g. 959.7, "Injury, other and unspecified, Knee, leg, ankle and foot."


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## ohn0disaster (Mar 21, 2011)

If they are coming in with an acute injury from an MVA, you would code the injury first THEN the incidental finding of DJD. And yes, the Ecode as well for the MVA. The same would go for an accidental fall or otherwise. The injury first, then the incidentals.


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## vballew (Mar 21, 2011)

Vanessa,

Is this because of it being a car accident?  Wouldn't that mean you are coding signs and symptoms first?  Is this only when the patient comes in with an injury that it is coded in this order?


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## ohn0disaster (Mar 21, 2011)

The injury is due to the MVA, not DJD. Therefore, it would not be coding signs and symptoms of DJD. DJD just happened to be an incidental finding when looking for any other complications of the MVA/injury. 
Regardless though, as far as I know, the circumstances of the patient encounter always take precedence in the selection of principal/ first-listed diagnosis. If the patient had come in with severe pain to the knee due to a MVA, xray was done and a fracture was shown, then you would no longer be coding the knee pain due to the fact that you now have a definitive diagnosis for the cause of the pain (making the pain a sign/symptom).

The easiest way for me to explain it is, the reason the patient came is was because of an injury secondary to a motor vehicle accident. After x-raying the area, no more of a definitive diagnosis was found. Therefore, you would code FIRST the reason shown to be chiefly responsible for the services provided (injury). Then you would code any additional codes that describe any co-existing conditions (DJD). In some cases, the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician.

This is all covered in your Official ICD-9-CM Coding Guidelines for Coding and Reporting, in *Section II. Selection of Principal Diagnosis* and *Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services*, for inpatient and outpatient coding respectively.

Hope this helps!


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