Orthopedic Coding Alert

Healthcare providers often discuss fractures in a language peculiar to the specialty involved. Not only must the physician understand this language, but so must coders. Often, the appropriate code selection depends on knowing the precise description of the fracture pattern.

Providers classify fractures according to four criteria:

1. the bone involved

2. the fracture's location

3. the pattern of the fracture fragments

4. the amount of anatomic disruption.

The bone involved is obviously critical for choosing the correct ICD-9 and CPT codes. Thus, we-ll examine the definitions of the other fracture descriptors, and see how they affect coding.

The first step in identifying a code for a patient's fracture treatment is to know where the fracture occurred. The following list should help you nail down an accurate location:

Diaphysis: The diaphysis is the main shaft of long, tubular bones. If your surgeon calls the fracture "a diaphyseal fracture," he is referring to a shaft fracture for coding purposes.

Physis: The physis, colloquially called the "growth plate," is present only in a growing bone. It is the cartilaginous growth plate that occurs near the end of a long bone. At skeletal maturity, the physis ossifies and fuses with the epiphysis and the metaphysis. Many of these fractures are intra-articular and are discussed in more detail below.

Epiphysis: The epiphysis is the end of a long bone between the physeal cartilage (physis) and the articular cartilage. Fractures through the epiphysis are virtually always considered intra-articular.

Metaphysis: The metaphysis is the flared end of a long bone and is located between the diaphysis and the physis. You probably won't find any coding significance regarding this region. Fractures through the metaphysis are usually considered part of the shaft for coding purposes.

You-ll have trouble pinpointing a CPT code unless the physician outlines whether the patient suffered a closed or open fracture. Here's a breakdown of how to identify fracture patterns:

Closed fracture: A closed fracture is one in which the skin is intact overlying the fracture and its hematoma.

Open fracture: An open fracture, formerly called a "compound fracture," is one in which there is a break in the integument at the fracture site or fracture hematoma. The size of the break in the skin is immaterial in classification as an open fracture, although it carries prognostic significance. You may see these described as Grade I, Grade II or Grade III (and there are subclassifications of those), but for coding, the only important distinction is open or closed.

For coding purposes, the ICD-9 codes are similar for closed and open fractures, but differ by the first digit after the decimal. For example, 823.2x describes a closed tibial shaft fracture, whereas 823.3x refers to an open tibial shaft fracture. When coding surgery, you-ll choose the same CPT code for fracture fixation regardless of whether the fracture is closed or open. But open fractures are virtually always cleaned out -- or debrided -- and this allows you and the surgeon to report an additional code from the 11010-11012 series (Debridement - associated with open fracture[s] and/or dislocation[s]).

The surgeon almost always debrides down to, and includes, the bone, thus the debridement code you-ll most commonly choose would be 11012 (Debridement including removal of foreign material associated with open fracture[s] and/or dislocation[s]; skin, subcutaneous tissue, muscle fascia, muscle, and bone).

Simple fracture: A simple fracture is when a single fracture line exists so that the bone divides into only two separate fragments.

Comminuted fracture: A comminuted fracture is one in which the fracture lines divide the bone into more than two fragments. There are subclassifications of comminuted long-bone fractures, but you should remember that a fracture with 100 fragments and one with two large fragments and a smaller one are both considered comminuted. There is, however, a difference in prognostic significance.

For coding, the only difference in simple fractures and comminuted fractures occurs for distal radius fractures. You-ll report 25607 for open treatment of an extra-articular distal radius fracture (a fracture that does not involve the joint surface of the distal radius).-Code 25608 applies when the physician treats an intra-articular distal radius fracture that is not comminuted. And you-ll report 25609 for a comminuted intra-articular distal radius fracture. Otherwise, the codes for treating simple and comminuted fractures are the same.

There may also be some coding importance when a fracture is severely comminuted, in that you may be able to append modifier 22 (Unusual procedural services) for fixation of a fracture broken into multiple large fragments, all of which the surgeon fixes internally.

Extra-articular fracture: An extra-articular fracture is one in which the fracture line does not enter a joint cavity.

Intra-articular fracture: An intra-articular fracture is one in which the fracture line enters a joint cavity. Note that the fracture can be intra-articular but not go through the articular, or joint, surface. You might see this referred to as an "intra-capsular" fracture. The most common location in which this occurs is the hip joint -- femoral neck or basicervical fractures are intra-capsular but do not involve the femoral head's articular surface. It may also occur at the knee on a proximal tibia fracture.

Several ICD-9 and CPT codes make a distinction as to whether a fracture is at the joint line or more in the mid-shaft. Most extra-articular fractures are in the shaft of long bones, or possibly the metaphysis (see above).

Transverse fracture: A transverse fracture is one in which the fracture line is perpendicular to the long axis of the involved bone.

Oblique fracture: An oblique fracture occurs when the fracture line intersects the long axis of the involved bone at an oblique angle.

Spiral fracture: A spiral fracture is an extreme case of an oblique fracture in which the plane of the fracture through the bone rotates about the bone's long axis.

Longitudinal fracture: A longitudinal fracture is parallel to, or nearly parallel to, the long axis of the involved bone. These are fairly rare.

Impacted fracture: These fractures are due to a compressive force that causes the end of a bone to be driven into the bone's contiguous metaphyseal region without displacement. An impacted fracture, however, may be angulated or rotated.

Pathologic fracture: A pathologic fracture is a fracture through abnormal bone.

Stress (or fatigue) fracture: Considered by some to be a type of pathologic fracture, this is a fracture through normal bone that has been subjected to cyclic loading at loads that, acting singly, are not sufficient to cause an acute fracture.

There are separate ICD-9 codes for pathologic and stress fractures, which can be included on the claim along with the basic ICD-9 code for the fracture. You should code pathologic fractures as 733.1x, and stress fractures are 733.93-733.95, depending on location. With stress fractures, you may frequently use another ICD-9 code for osteoporosis (733.0x).

Stress fractures usually occur in only two categories of patients -- overuse injuries in very active people (military recruits is the classic example), or fractures through weakened bone, such as osteoporosis, occurring from relatively normal activity. An argument can be made that patients with severe osteoporosis actually sustain a pathologic fracture because the bone is not normal.

The following list of fracture types can help you match the surgeon's terms with the CPT book:

Greenstick fracture: A greenstick fracture is an incomplete fracture in which only one cortex is broken while the opposite cortex and periosteum remain intact.

Torus fracture: A torus fracture is an impaction injury in which the cortex of a long bone buckles with no loss of cortical continuity. This is often called a "buckle" fracture and is most commonly seen at the distal radius, although it can occur in the tibia.

Plastic deformation: Plastic deformation occurs exclusively in children's bones when a bone simply bends with no break in either cortex. Children's bones are more porous and, consequently, less brittle.

The above three fractures always occur in children and are almost always treated closed, with some form of external immobilization (cast, splint or brace).

Physeal injury: This is an injury through the physeal plate in a developing child. These injuries have their own system of description and are discussed in more detail below.

Dislocation: Dislocation is technically defined as total loss of congruity between a joint's articular surfaces. If the patient suffers anything less than total loss of congruity, you should strictly consider the injury a subluxation.

Extreme subluxations ("near dislocations") are often termed dislocations, but this is not technically correct. Occasionally, people (often the media) describe tendons or other soft-tissue structures as dislocated. Although orthopedic surgeons also fall into this trap, only a joint can actually be dislocated.

In addition to describing the fracture's location and the fracture line and fragment pattern, you also need to be able to describe the degree of anatomic disruption. Loss of normal anatomy can occur because of displacement, angulation and rotation.

For coding purposes, there is no distinction in ICD-9 or CPT codes as they relate to anatomic disruption. On the other hand, occasionally being able to fully describe the fracture disruption (or displacement) may assist you in getting approval for a surgery. Look for these terms in your orthopedist's fracture care documentation:

Displacement: A measure of the translational distance between the corresponding cortices of the fracture fragments.

Angulation: Angulation measures the angle between the longitudinal axes of the main fracture fragments. Being able to describe the direction of angulation is important, and this can cause difficulty because different texts describe angulation using different methods.

Suppose your surgeon treats a tibia fracture with the fragments angulated such that the distal end of the distal fragment points laterally. Saying that the fracture is angulated into valgus (distal fragment directed laterally) would be appropriate. Some authors also describe this fracture as angulated laterally, meaning that the distal fragment is directed laterally, while others would call this medial angulation, meaning that the fracture's apex is directed medially. But there is no similar analogy to describe anterior-posterior angulation. For consistency, the physician should describe the direction of the apex of an angulated fracture (for example, apex medial, apex dorsal, etc.).

Rotation: Rotation is a twisting about the longitudinal axis of one of the fracture fragments. It is the most difficult type of fracture disruption to see on radiographs, and it is also the deformity that remodels the least as the fracture heals. Rotation can be evaluated better clinically than it can be radiographically.

Children's fractures can be more difficult to describe accurately because of the presence of the physis, or growth plate. You-ll find several classification systems for fractures involving the physis. By far the most widely used is the Salter-Harris system, which is as follows:

Salter-Harris Type I: In this injury, the fracture line goes directly through the physis. This would usually be an extra-articular fracture. You cannot always clearly see this fracture on radiographs, and sometimes provider must make the diagnosis on clinical suspicion.

Salter-Harris Type II: In this injury, the fracture line is mostly through the physis, but it exits one cortex such that a small fragment of metaphysis is included with the fracture fragment containing the physis and epiphysis. This would usually be an extra-articular fracture.

Salter-Harris Type III: In this injury, the fracture line is mostly through the physis, but it exits one cortex such that a small fragment of epiphysis is included with the fracture fragment containing the metaphysis and diaphysis. This fracture is always intra-articular.

Salter-Harris Type IV: In this injury, a fracture line crosses the physis such that both fracture fragments contain portions of the metaphysis, physis and epiphysis. This fracture is always intra-articular.

Salter-Harris Type V: With this injury, there is no definite fracture line, and like the Salter-Harris Type I, this injury cannot be easily diagnosed radiographically. This involves a crush injury to the physis in which the metaphysis and epiphysis are acutely impacted upon one another. This would be an extra-articular fracture.

You may also come across subclassifications of several of the above categories, but these would not be significant for coding purposes.