ED Coding and Reimbursement Alert

Question: What exactly is an open fracture? We are having a debate in the coding office. One coder says an open fracture occurs when the physician has to open up the surgical site to treat the fracture, but I say it's when the bone comes through the patient's skin. Who's right?

Louisiana Subscriber

Answer: You are both right. Now it depends on whether you are talking about CPT procedural coding or ICD-9 diagnosis coding.

From an ICD-9 perspective, open fractures occur when a bony fragment sticks through the skin (the fracture may also be called -compound-), or there is an opening between the skin and the fracture. Indications that the fracture was open might include wording such as  -compound,- -missile,- -puncture,- -open- or -with foreign body.-

In a closed fracture, the skin remains intact with no protruding bone at the site. Closed fracture terminology might include terms like -comminuted,- -transverse,- -depressed,- -elevated,- -fissured,- -greenstick,- -impacted,- -linear,-  -march- and -simple.- In addition, most stress fractures are closed fractures.

Tip: Of note, don't confuse an open fracture diagnosis with open treatment. Most ED scenarios do not involve open fracture treatments because they generally require a trip to the operating room. See page 73 of the CPT manual for additional description of open vs. closed treatment.

More help: Here's a list of terms the ED physician might use to describe a patient's fracture:

- Avulsion -- In some instances, the attachment of a tendon or ligament to the bone is strong enough to cause a piece of bone to tear away from the rest the bone, usually in a joint.

- Burst -- A vertebral fracture that is more severe than a compression fracture. In this type of fracture, fragments are forced posteriorly toward the spinal canal.

- Butterfly -- An extra bone fragment seen in comminuted fractures, which is often shaped somewhat like a butterfly.

- Chip -- This refers to a small piece of bone usually near a joint or condyle.

- Comminuted -- A fracture with more than two fracture fragments. Usually this type of fracture is traumatic in nature.

- Complete -- The fracture involves the entire bone cortex.

- Compression -- Seen in vertebral body fractures where the cancellous bone is compressed.

- Depressed -- When a bone that is part of the fracture is pushed down below the level of the skull or joint it is related to, then this is considered depressed.

- Displaced -- In some cases the fractured bone fragments are moved apart from each other, and this is considered displaced.

- Epiphyseal -- A fracture of the epiphysis and physis, or growth plate. 

- Greenstick -- This type of fracture is always found in children and is an incomplete fracture leaving a partial break that is often angulated. 

- Hairline -- These fractures represent a crack in the bone that is not complete.

- Impacted --A fracture in which one broken end is wedged into the other broken end.

- Segmental -- Multiple fractures on the same bone in which several large pieces of bone have broken away.

- Spiral -- This is also referred to as a -torsion- fracture because the bone ends of the fracture are spiral shaped. This is usually seen in long bones.

- Stress --A crack in the bone, often from excessive physical exertion. This will show up on later radiographs after callus formation begins but may not be noticeable on initial radiograph. Also termed an -insufficiency fracture.-