Anesthesia Coding Alert

Take a look at the musculoskeletal system to handle documentation complexities.

Fracture coding will be one of the biggest challenges after ICD-10 implementation because of the number of choices available. You need to know the following anatomical and diagnostic details to code a fracture in ICD-10 when your anesthesiologist is involved in a fracture case:

• Anatomic site on bone (proximal, shaft, distal)
• Laterality (right or left)
• Fracture Type (displaced, non-displaced, open or closed; if open there are 3 more subsets to choose from)
• Episode of care (initial, subsequent, or sequela). 

When gathering these details, keep the following steps in mind to pinpoint the best diagnosis. 

Step 1: Record Every Single Details

Let’s walk through some examples to explain how you’ll choose the best fracture diagnosis code. 

Example 1: The hospital record documents the diagnosis as “fracture radius shaft.”

ICD-9 coding: With this information you can comfortably code 813.21 (Fracture of radius and ulna, shaft closed, radius alone).

In ICD-10 we have to code it with the addition of laterality, the fracture type, and the episode of care. ICD-10 offers 270 choices for this injury.  For this example, imagine that you’re coding for the initial episode of care for a closed and non-displaced transverse type fracture on the patient’s right side. 

You would report S52.324A, based on the following code details:

• S52.3 – Fracture shaft of radius
• S52.32 – Transverse fracture of radius
• S52.324 – Nondisplaced transverse fracture of shaft of RIGHT radius
• S52.324A – Nondisplaced transverse fracture of right radius, initial encounter for closed fracture. 

Example 2: The anesthesia record reports a fractured tibia. In ICD-9 coding, you would report this condition as 823.80 (Fracture of tibia and fibula, unspecified part, closed, tibia alone).

With ICD-10, you cannot code appropriately with so little information. For the sake of the example, suppose the details were: the right side, closed, displaced oblique type fracture, proximal tibia, initial encounter. You would code this particular diagnosis as S82.121A: 

• S82.12 – Fracture of lateral condyle of tibia
• S82.121 – Displaced fracture of lateral condyle of right tibia
• S82.121A – Displaced fracture of lateral condyle of right tibia, initial encounter for closed fracture.

Step 2: Get Necessary Information for Payment 

Not many conditions will have an option of “not otherwise specified” codes in ICD-10. Therefore, your anesthesia provider will have to document all this additional information at the time of surgery-- or you might need to query the surgeon’s office afterwards to get all the needed information.

Many anesthesiologists include laterality in their notes and some will document whether a fracture is open or closed. It can be rare, however, to see more information in the anesthesia chart regarding the patient’s diagnosis. Reminding your providers that they won’t get paid adequately under ICD-10 without those details could give them the incentive to better document their services. 

Bonus: A good head start for preparing for ICD-10 would be to include specific and complete diagnosis information in your anesthesia records. It that becomes a habit, ICD-10 compliance will be easier and your claims will be completed with fewer questions from coders and fewer denials from payers.