Neurosurgery Coding Alert

Question: The surgeon performs an open reduction on a patient with an unstable closed burst fracture of the L2 vertebrae. The surgeon then performs a follow-up inpatient consult two days following the surgery. Should I code the diagnoses as S32.002A and Z47.89?

New York Subscriber

Answer: You are correct in coding an unstable closed burst fracture of the L2 vertebrae as S32.002A (Unstable burst fracture of unspecified lumbar vertebra, initial encounter for closed fracture). However, remember that you shouldn’t include an aftercare code when the primary code includes a seventh character. In this case, the seventh character explains that this patient is receiving initial treatment for the diagnosed fracture. Therefore, the use of code Z47.89 (Encounter for other orthopedic aftercare) is both redundant and unnecessary.

Some coders may argue that since this is technically a follow-up surgical visit, the seventh character should be D (Subsequent encounter). However, you should classify the postoperative state for treatment of a fracture as part of the patient’s initial encounter. For further clarity, ICD-10 defines subsequent encounters as “encounters after the patient has received active treatment of the injury and is receiving routine care for the injury during the healing or recovery phase.”

By this definition, the patient clearly would not qualify for the subsequent-encounter seventh character. When the patient returns for a follow-up imaging to see the progress of the fracture’s healing, you would code the fracture diagnosis with a D character (unless the fracture has not healed normally).