Orthopedic Coding Alert

Get to know the fracture terms in-depth, and the right diagnosis and procedure codes will follow

Can you differentiate a boxer's fracture from a Bennett fracture? Do you know the difference between a depressed fracture and a greenstick? If not, it's time for a quick reminder of these fracture types, and you-ll increase your coding savvy quickly and easily.
 
Because your orthopedic surgeon won't always dictate his notes using the same terms you-ll see in the CPT and ICD-9 manuals, a firm grasp of anatomic knowledge is important. For the next few months, Orthopedic Coding Alert will be running a column in each issue that can help you connect anatomic terminology to the right diagnosis and CPT codes. In this issue, we-ll break down fracture care and how each term fits into your claims process.

Differentiate Between Closed and Open Fractures

Most orthopedic coders can't go a whole day without coding a fracture chart. Because fractures make up so many diagnoses in orthopedic practices, it's important to learn the terminology that physicians use when describing these conditions.

Your first step should be to determine whether the physician treated an open or closed fracture. If you look at the ICD-9 Manual, you-ll note that most fractures are listed first by site, and then according to whether the fracture is closed or open.

For example: Suppose your surgeon diagnoses a patella fracture. In the index of the ICD-9 manual, you look up -fracture,- after which you will see a listing of the sites. If you move to -knee,- the subheading will say -closed 822.0,- followed by -open 822.1.- Therefore, if you don't know whether the surgeon diagnosed an open or closed fracture, you won't be able to assign an accurate code.

Closed fracture -- Closed fractures refer to fractures in which the skin remains intact, with no broken skin or protruding bone at the site, as seen below. Look for terms like -comminuted,- -transverse,- -depressed,- -elevated,- -fissured,- -greenstick,- -impacted,- -linear,-  -march- and -simple.- In addition, most stress fractures are
closed fractures.

Tip: Unless the term -open- or -compound- appears in the diagnostic statement, you should most likely report a closed fracture code, according to the American Hospital Association's Coding Clinic.

Open fracture -- The end of a bony fragment sticks through the skin (the older term is -compound fracture,- which some physicians may still document), or there is an opening between the skin and the fracture. -The precise technical definition is that the fracture hematoma communicates with an open wound,- says Bill Mallon, MD, orthopedic surgeon and medical director at Triangle Orthopaedic Associates in Durham, N.C.

You can know for sure whether your physician treated an open fracture if the documentation includes the words -compound,- -missile,- -puncture,- -open,- or -with foreign body.-

Familiarize Yourself With Specific Fracture Types

Surgeons may refer to the patient's fracture based on the fracture's features, so you should keep the following list near your ICD-9 Manual in case you need to look up any of these terms:

 - 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 specific type of vertebral fracture, which 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, this is considered depressed.

 - Displaced -- In some cases, the bone fragments of a fracture 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 from the bone.

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

Some Fractures Have -Proper Names-

Orthopedic surgeons won't always dictate fractures using terms such as -closed fracture of the distal radius and ulnar styloid.- Instead, they may simply refer to a -Colles- fracture- and expect the coder to know which ICD-9 code applies.

You should learn the following types of fractures, which physicians may call by name:

 - Bankart fracture -- This is usually seen with an anterior dislocation of the shoulder where a small piece of bone is detached from the anterior inferior rim of the glenoid bone.

 - Bennett fracture -- The thumb is dislocated dorsally at the metacarpal. There is also an associated avulsion of the metacarpal on the volar surface of the metacarpal articular surface.

 - Boxer's fracture -- A fracture typically of the fourth and/or fifth metacarpal that is impacted and displaced volarly.

 - Colles -- This refers to a fracture through the distal radius and often the ulnar styloid. This type of fracture is known to produce a -silver fork deformity.-

 - Dupuytren fracture -- A spiral fracture found at the distal end of the fibula.

 - Galeazzi -- A fracture of the radius at the junction of the middle and distal thirds with distal radioulnar joint dislocation.

 - Holstein-Lewis -- Spiral fracture to the humeral shaft.

 - Jones -- A fracture through the metaphysis of the proximal end of the fifth metatarsal.

 - Lisfranc -- A fracture and dislocation of the joints in the midfoot.

 - Maisonneuve -- A proximal fracture of the fibula resulting from external rotation.

 - Monteggia -- This fracture involves the proximal one-third of the ulna with dislocation (in any direction) of the radial head. This results in the ulna fracture fragments riding over one another.

 - Pilon -- A comminuted fracture of the distal tibial articular surface.

 - Plafond -- A fracture that involves the surface of the distal tibia where it meets the talus bone.

 - Salter-Harris -- A fracture of the epiphyseal growth plate in children.

 - Smith fracture -- This is the reverse of the Colles, as the distal fragment of the radius is dislocated volarly.

 - Tillaux -- A fracture of the lateral portion of the distal tibia, this type of fracture is commonly seen in adolescents.

Example: Your surgeon documents an open Galeazzi fracture.

Solution: You should report 813.52 (Fracture of radius and ulna; lower end, open; other fractures of distal end of radius [alone]) for this diagnosis.