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Home Health ICD-9/ICD-10 Alert

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Keep Acute Fracture Codes In Their Place

Published on Sun Aug 12, 2007

Question: We are providing physical therapy and occupational therapy to treat gait abnormality for a patient who fell and fractured her lower leg and lower arm. Which codes should we report? Should we report an acute fracture code for this patient?

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Answer: If the patient has suffered recent traumatic fractures on the lower leg and lower arm and the reason for admission is to restore gait, you should code for it as follows, says Jun Mapili, PT, MAEd, with Global Home Care in Troy, MI:

  • M0230a: V54.16 (Aftercare for healing traumatic fracture of lower leg);
  • M0240b: 781.2 (Abnormality of gait);
  • M0240c: V54.12 (Aftercare for healing traumatic fracture of lower arm); and
  • M0245a: 781.2 (Abnormality of gait) or 823.8x (Fracture of tibia and fibula; unspecified part, closed).

While acute fracture codes (800-829) and pathologic fracture codes (733.1x) are appropriate when the patient is receiving active treatment such as surgical treatment, emergency department encounters, or evaluation and treatment by a new physician, these codes don't represent the care provided by home health agencies.

Look instead to aftercare codes (subcategories V54.0, V54.1, V54.8, or V54.9) for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase, Mapili says. Examples of fracture aftercare include cast change or removal, removal of an external fixation device, medication adjustment, and follow-up visits after fracture treatment.

If the physician states that the fracture is traumatic, the aftercare code should come from the V54.1x subcategory; if it's pathologic, look to V54.2x instead.

Keep in mind: A fracture sustained with a fall does not automatically denote traumatic fracture; if the major cause is pathologic such as osteoporosis and the fall is only a contributing/triggering factor then the fracture would be considered pathological, Mapili says. Either way, only the physician can state that the fracture is pathological or traumatic; verification from the physician is always needed when the information lacks specificity.

If you have the confirmation that the fracture is traumatic, then you can report V54.12 for the lower arm and V54.16 for the lower leg. Deciding which code to report as the principal diagnosis in M0230 depends on the severity of the fractures and the focus of care.

Some clinicians and coders would report V57.89 (Multiple training or therapy) for M0230 in this case because both PT and OT are involved. However, the fracture aftercare code is more specific.

With physical therapy and occupational therapy prescribed, you may want to include a treatment diagnosis such as gait abnormality (781.2) if the main goal is to restore gait.

Don't forget: Include case-mix diagnosis code 781.2 in M0245 to get the extra points.

Another option is to place the fracture code in M0245a. This would be especially appropriate if the focus of care is more than gait abnormality. Even though the fracture codes cannot be reported in M0230 or the M0240s, they can appear in M0245 because the code(s) in M0245 do not get directly reported on the claim.

You'll gain the same number of points for abnormality of gait or a trauma fracture, but the risk adjustment on several of the outcomes is better when using the fracture codes. The underlying diagnosis to the V54.1x code is the fracture, so if V54.1x is in M0230, the fracture code rightfully belongs in M0245. Abnormality of gait is a symptom code and it's appropriate to list if one aspect of care is being provided (gait training) and/or the definitive diagnosis is no longer current.



 

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