ED Coding and Reimbursement Alert

You’ll need to amp up your fracture coding skills under ICD-10 to ensure that emergency department visits for traumatic fractures are appropriately differentiated from patients who present to the ED with spontaneous, pathological or recurrent fractures.

ICD-10 manual: Get familiar with Chapter 19:  Injury, poisoning and Certain Other Consequences of External Causes S00-T88.   You’ll turn to Chapter 13 Diseases of the Musculoskeletal System and Connective Tissue (M00---M99) for spontaneous or recurrent fractures , says Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, Chief Executive Officer of Edelberg Compliance Associates.  

Learn From This  Traumatic Fracture Example

 A 12 year old presents to the ED with a broken middle finger on his right hand sustained in a fall from his bike.  The emergency physician must document the following to assure coding can appropriately identify the injury:

1. the exact bone fractured (proximal, medial, distal or unspecified phalanx)
2. confirm the location of the injury (right hand)
3. Whether the encounter is initial, subsequent or sequela

So, in this example, the emergency physician confirms a displaced closed fracture to the medial phalanx of the right middle finger (S62.622X).  Codes from this section require a 7th digit to identify the type of encounter (A-initial, D-subsequent, S-sequela), type of fracture (open/closed), and, if subsequent, whether the encounter is for routine healing, delayed healing, nonunion or malunion).  

Key: In this case, this is the initial encounter for a closed fracture so the appropriate code is S62.622A, says Edelberg.

Bone Up on Pathologic Fractures and Dislocations

A pathologic fracture occurs when a bone breaks in an area that is weakened by another disease process. Causes of weakened bone include tumors, infection, and certain inherited bone disorders. There are dozens of diseases and conditions that can lead to a pathologic fracture or dislocations, says Edelberg. 

A pathologic fracture or dislocation usually occurs with normal activities--patients may be doing very routine activities when their bone suddenly fractures or dislocates. The reason for a fracture is that the underlying disease process weakens the bone to the point where the bone is unable to perform its normal function, Edelberg explains. 

For example, a bone cyst may grow to a significant size where the tumor effectively eats away a significant portion of normal bone. This area of bone is now much weaker, and prone to pathologic fracture. 

 Similarly, pathological dislocations, particularly shoulders, are often treated in the emergency department.  These dislocations occur without trauma but occur with normal motion.  They may also be referred to as spontaneous dislocations, Edelberg adds.

Nail Down Spontaneous Dislocation

Say, for instance, your emergency physician manipulates a right shoulder that spontaneously dislocated with normal movement.  The patient states that this is a recurrent problem.  In this example, the emergency physician must identify the following elements of the injury:

1. Type of Injury (recurrent, spontaneous dislocation)
2. Underlying disease process if applicable (N/A)
3. Location of Injury (right shoulder)

What to code: For this injury, M24.411 (Recurrent dislocation, right shoulder) is applicable.  ICD-10 reminds the coder to check the 6th digit which specifies the exact location of the injury (1-right; 2-left; 9-unspecified).  Note:  Although coding of “unspecified” should not incur penalties for payment, you should always document and bill for the exact site when possible.  Coders should be prepared to work with physicians on individual cases where the exact site is not identified, advises Edelberg.

How to Handle “Not Otherwise Specified” Designation There is no 7th character for “not otherwise specified” or unspecified episode of care. And for fractures, there is not a “not otherwise specified” designation for open/closed fractures or for the Gustilo classification when that is required. Guidelines do state that if the fracture is not documented as open or closed, it is coded as closed, says Edelberg.

Challenge: Assigning episode of care 7th characters for fractures is a bit more complicated than for other injuries, because the episode of care provides additional information about the fracture, including whether the fracture is open or closed, and during the healing phase whether healing is routine or with complications such as delayed healing, nonunion, or malunion. Just to complicate things a bit more, 7th character extensions for some open fractures capture the Gustilo open fracture classification, Edelberg warns.

Bottom line: Coding of fractures and dislocations will require a higher level of documentation and coding to provide a complete description of the injury, its cause, its episode of treatment and, where appropriate, numerous additional elements required by ICD-10, Edelberg advises.  Physicians and coders may want to focus additional attention on these injuries to minimize coding problems after implementation of ICD-10.