Orthopedic Coding Alert

Closed fractures can present mind-boggling coding challenges, with many different types of treatment available to the orthopedist who devotes much of his or her time treating these injuries. Knowing how to accurately report diagnosis and treatment codes, especially with E/M services and global packages in mind, is the first step to ethical reimbursement.
Fracture Primer
ICD-9 code descriptors specify a fracture's location and whether it is closed or open (e.g., 821.21, Fracture of femur, condyle, femoral, closed).
 
Closed fracture refers to a fracture where the skin remains intact: There is no broken skin or protruding bone at the fracture site. Code descriptors for closed fractures might include terms like "comminuted," "depressed," "elevated," "fissured," "greenstick," "impacted," "linear," "march," "simple," "slipped epiphysis," "spiral" or "unspecified." Use a closed fracture code unless the term "open" appears in the diagnostic statement.
 
Open fracture refers to a fracture where the skin is broken at or near the fracture site, often as a result of protruding bone. These injuries usually contain foreign material (dirt, gravel, glass or clothing fibers) and are prone to infection. Open fractures may also be referred to in ICD-9 as "compound," "infected," "missile," "puncture" or "with foreign body."
 
A fracture can be described using both closed and open fracture terminology, such as a compound, comminuted fracture of the femoral shaft. Code this type of fracture as open: 821.11 (Fracture of femur, shaft, open).
 
Physicians frequently describe a fracture with an associated dislocation, such as a fracture-dislocation of the left first tarsometatarsal joint. Code these fractures to the type of fracture and not the dislocation; in this case, 825.25 (Fracture of metatarsal bone[s], closed) would be appropriate.
 
CPT list the following categories of treatment:
 
Closed treatment is described in the Musculoskeletal System section of CPT 2002: "The fracture site is not surgically opened (exposed to the external environment and directly visualized). This terminology is used to describe procedures that treat fractures by three methods: 1) without manipulation 2) with manipulation 3) with or without traction." In these cases, the fracture is set through splinting, strapping or casting with or without the application of manual force or reduction. Some closed fractures can require skeletal traction, where pins or wires are attached to the bone. This is still closed treatment of a closed fracture, because the fracture site was not incised to access the bone.
 
Open treatment is also described: "The fracture is surgically opened (exposed to the external environment). In this instance, the fracture (bone ends) is visualized and internal fixation may be used." Open [...]