# HELP w/ Traumatic Pelivc Fracture;  MCR Case



## joanne71178 (Jun 18, 2013)

POSTOP DIAGNOSIS: 
1. Multiple site disruption of the pelvic ring including a Malgaigne fracture dislocation of the left hemipelvis and right sacral fracture. 
2. Pelvic external fixation and left femoral traction pin.

OPERATION PERFORMED:
1. ORIF Left Iliac fracture
2. ORIF Left sacroiliac disruption with sacroiliac screw
3. Percutaneous sacroiliac screw fixation of Right sacral fracture
4. ORIF pelvic symphysis diastasis
5. Removal multi-plane external fixator and Left distal femoral traction pin

INDICATIONS: 'The patient is an 80 year old who fell from a tree resulting in major pelvic trauma. The patient was initially stabilized with external fixation and teaction and is now stable enough for the major reconstructibe procedure. I discussed with the patient the benets, risks and alternatives and he gives informed consent. 

FINDINGS AND PROCEDURE: The patient was identified and taken to the operating room where he was made comfortable on the transport stretcher, then intubated and sedated. He was then transferred onto the operating room table and was placed into left leg skeletal traction with a traction post in place. His right leg was placed into a boot holder to prevent heel ulceration during the prolonged procedure. Two folded blankets were placed behind the sacrum and lumbar spine to allow for access. the pelvis was then prepped and draped in the usual sterile fashion. 
A surgical pause was performed. He had been on antibiotics. The external fixator frame had been removed prior to prepping. 

An incison was marked out along the left posterior iliac crest and then was infused with local anesthetic. The skin was divided and, on blunt dissection of the subcutaneous tissues , there was a plane that could be developed without any sharp dissection all the way to the iliac wing and into the iliac fossa. The large hematoma was evacuated and cautery was used to obtain hemostasis where possible. The fracture of the iliac wing into the sacroiliac joint and the disruption of the sacroiliac joint were palpable. The debris and clot material were then cleared from the fracture site and then the left hemipelvis was manipulated through the external fixator pins and traction until there appeared to be good reduction of the sacroiliac disruption and the iliac fracture. A guide wire for the 7.3 cannulated screw set was then placed to temporarily pin from the ileum to the sacrum holding the provisional reduction. A long guide pin from the [_] reduction clamp set was then placed on the internal surface of the ilium parallel to the sacroiliac joint. The pin was then advanced under fluoroscopic guidance down the posterior ilium parallel to the sacroiliac joint and then depth was sounded and this was over drilled. A 7.3 screw with washer was then advanced throught an incision that had been localized on multiple views with fluoroscopy. This was then passed down tot he outer table of the ileum and then was advanced under fluoroscopic guidance into the body of the sacrum above the S1 foramen. A second pin was then placed in a slightly different position for comparison. 

The right sacral fracture through the SI joint was then addressed through a separate incision and treatment plan. A guide wire for the 7/3 cannulated screw system was then passed down through the right gluteal region to the outer table of the ilium and then this was advanced under fluoroscopic guidance into the body of the sacrum above the S! foramen. A second pin was placed slightly more anterior superior and then the 0-arm was brought in to the check positioning. The more anterior superior pin was selected on the right side and ont he left side there appeared to be some concern about the pin approaching too closely to the S! foramen. 
A pin was then reposition more anteriorly in the sacrum and then this was over drilled. A 7.3 cannulated screw with washer was then passed over the guide wire and this was used to compress the left sacroiliac disruption . ON the rightdide, a partially threaded screw was placed but this was not heavily compressed to avid shearing of the sacral fracture. 

The following represents a separate approach and separate hardware for the treatment of the symphysis diastasis. An incision was marked out in the suprapubic-region and then this was carried down through skin to the subcutaneous fat and connectivbe tissue and then down to the rectus musculature and fascia. The fascia had been largely avulsed from the right side of the pubis and on the left side the tissues were elevated to allow for placement of an anterior plate. The clot and tissue were then removed from the sympysis region and the external fixator was placed under towel tension after which a pointed reduction tenaculum was applied to the anterior pelvis and then , as the urethra was held down to make sure it was not entrapped within the sacrum, the pelvic clamp was closed and this reduced the symphysis. 
A Synthes six-hole symphyseal locking plate was then selected and then this was anchored using a standard 3/5 mm screw on the right side, passing vertically in the pubis. A locking screw was then placed on the left side of the pelvis in the number three hold providing provisional stability. A locking screw was then added on the right side in the number two hole and then the original 3/5 compression screw was removed from the first hole and this was replaced with a 4.5 standard screw. The left side first hole was then drilled and a 4.5 screw was placed. The final locking screw was then placed on the riht side in the number three hole and all hardware appeared to be in appropriate position and the disruption appeared to be well reduced. 

The wounds were then copiously irrigated as the external fixator pins were removed. "

I coded 
27216 58 59 LT
27218 58 RT
27218 58 LT
27217 58 
20694 58
11044 58
76000 26 59

THESE codes were denied ( not covered by Medicare) even though this is a trauma case. Any thoughts on these codes? Would anyone use different codes?  I appreciate any thoughts or advice.


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## mitchellde (Jun 18, 2013)

Look at your dx code.  also was the initial stabilization coded as fx care.  Your dx code for the second surgery cannot be the acute fx code.


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## joanne71178 (Jun 18, 2013)

mitchellde said:


> Look at your dx code.  also was the initial stabilization coded as fx care.  Your dx code for the second surgery cannot be the acute fx code.


So I should not use the traumatic fracture code of 808.43? all others I see are stress or pathological. The TIP in the ICD( book says to use the acute fx code when patient is receiving active treatment for the fracture.   These CPC codes are not payable by Medicare, but were the surgeries performed how do I handle that?  I don't want to write off a $20,000 case.  Any suggestions?

The initial stabilization was coded w/ application of external fixation 20692 & skeletal traction 20650; dx 808.43, 805.6, E884.9. .


I appreciate your help!


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## mitchellde (Jun 18, 2013)

In ICD-9 the AHA coding clinics have stated that once the fx is initially treated, it can no longer be coded as an acute fx.  You need to code it as a non healing fx 733.82 or non union 733.81.  Medicare probably shows that this fx has already been treated and they will not cover it again.  Unfortunately there is no way in ICD-9 to code for a subsequent treatment of a fx, the best you can do is a nonhealing fx code. how many days are inbetween these procedures?  No you do not have to write it off, you just need to rethink the scenario.


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## joanne71178 (Jun 18, 2013)

mitchellde said:


> In ICD-9 the AHA coding clinics have stated that once the fx is initially treated, it can no longer be coded as an acute fx.  You need to code it as a non healing fx 733.82 or non union 733.81.  Medicare probably shows that this fx has already been treated and they will not cover it again.  Unfortunately there is no way in ICD-9 to code for a subsequent treatment of a fx, the best you can do is a nonhealing fx code. how many days are inbetween these procedures?  No you do not have to write it off, you just need to rethink the scenario.


It was 5 days between procedures.  So you think I should have AR appeal it with the 733.82 and remove 58 modifier?   The 5 days between surgeries the patient was in-house, unstable ,until day 5.  

 I do appreciate your help! Thanks!


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## mitchellde (Jun 18, 2013)

I go with the coding clinics definition of active treatment, which is the initial treatment.  the fracture was actively treated with stabilization and reduction.  The subsequent treatment was primarily for the purpose of internal fixation to keep the bones in correct anatomic position.  had the fx not been treated and tx delayed by 5 days then it is still an acute untreated fx.  If the stabilization was primarily establishing traction in the facility then I would not have reported this with a CPT code, It is not unusual to treat with traction only to allow the patient time for the vital signs to stabilize and then take them to the OR.  If this is the case,  I would have billed an assessment visit level and waited to bill the fx treatment.  Just depends on how it was documented.


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## joanne71178 (Jun 19, 2013)

After researching Medicare's reason for the denial of these codes I have found the correct codes for Medicare are G0412-G0415 instead of 27215-27218. Please see the AAOS link: 

http://www.aaos.org/news/aaosnow/mar10/managing2.asp

Be sure to click on Table 1


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## donnafm1109 (Nov 30, 2015)

*Multiple sacral fractures*

Regarding sacral fractures:

The patient had a right-sided S1 & S2 sacral fracture. Are these 2 fractures separately billable?


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