ICD 10 Coding Alert

Hint: Rely on these guidelines for 7th-character confusion.

Coding malunion/nonunion fractures can be a real bear, even for long-time coders who know their way around the ICD-10-CM code book.

Check your knowledge against this scenario to make sure your coding meets all the necessary standards.

Don’t Make the 7th Character an Obstacle

Scenario: Eight months following a traumatic closed right tibial shaft fracture, the patient undergoes a corrective internal fixation procedure to fix a formed malunion. A follow-up X-ray confirms the tibia has been properly aligned.

Reaching the first six characters of this diagnosis code is simple. You’ll report an unspecified closed fracture of the shaft of the right tibia as S82.201- (Unspecified fracture of shaft of right tibia). The problem, in this instance, is that final seventh character. Specifically, the dilemma centers around the application of the following two seventh characters:

• A, Initial encounter for closed fracture
• P, Subsequent encounter for fracture with malunion

At first, it may seem easy to make arguments, using the ICD-10-CM guidelines as justification, for both characters.

Section I.C.19.c of the ICD-10-CM guidelines states the following:

• “Traumatic fractures are coded using the appropriate 7th character for initial encounter (A, B, C) for each encounter where the patient is receiving active treatment for the fracture.”

Contrast that guideline with the following instruction on when to report a subsequent care seventh character:

• “Fractures are coded using the appropriate 7th character for subsequent care 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.”

Based on the above two guidelines, the answer seems to imply that this is a clinical scenario involving active treatment, thus warranting the use of seventh character A. However, the water gets murkier the deeper you dive into the guidelines. For instance, have a look at the following guideline, which seemingly argues in favor of seventh character P in the above scenario:

• “Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7th character for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R).”

Apply These Guidelines

So, on one hand, the information of the patient encounter suggests you’re coding a fracture receiving active treatment. However, the guidelines also state that care of fracture complications, including malunion, should be reported using a subsequent care seventh character. But before making up your mind, you’ve got one more portion of the ICD-10-CM guidelines to consider:

• “Malunion/nonunion: The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.”

Unfortunately, the guidelines don’t elaborate on what exactly it means for a patient to delay seeking treatment. However, you should operate as if this guidance applies to the following two scenarios:

• The patient delayed treatment for their initial fracture diagnosis; or
• The patient had treatment on their initial fracture diagnosis, but delayed treatment on their nonunion/ malunion to the point that it significantly complicated the treatment process.

Since malunion/nonunion are the result of a bone healing out of position or failing to heal at all, respectively, the amount of time a patient may wait in getting treatment on one of these two complications is subjective. The physician should indicate that the patient’s delay in seeking treatment following the complication resulted in additional interventional tactics. In this case, you would append an initial seventh character to the diagnosis.

Key advice: “Our job as coders sometimes requires us to put on our detective hats when analyzing reports,” says Chelsea Kemp, RHIT, CCS, COC, CDEO, CRC, CEDC, CGIC, Outpatient Coder 3 at Yale New Haven Health in New Haven, Connecticut. “Subtle clues, such as the provider comparing previous imaging results in the dictation, may help with the decision in selecting the appropriate seventh character. Documentation notes may even help to clarify whether the patient was seen previously for initial treatment of the fracture. Utilizing all aspects of the dictation report is an essential component of the code selection process.”

Don’t Forget: Query the Provider

As you can see, making a determination on seventh character reporting for malunion/nonunion fracture diagnoses depends squarely on the documentation you’re working with. As radiology coders, you’re not typically privy to documentation that, say, an orthopedic surgery coder may have access to. Instead, you’re left to the mercy of the dictation report and, more specifically, the indication of said report. In some instances, you simply won’t ever know whether the patient opted to delay their initial treatment of a fracture before getting treatment for a malunion/nonunion.

If you believe the seventh character of your fracture diagnosis code cannot be determined without knowing the patient’s treatment history, you need to request any additional information that will help ensure you’re coding compliantly. In the scenario above, you technically do not know whether the patient sought treatment on the closed fracture eight months prior. While the likelihood is that the patient saw the provider for initial treatment, and the current diagnosis requires a seventh character “P,” you should verify this in the patient’s chart before coding the claim.