Orthopedic Coding Alert

Best bet: Confirm side for closed fractures, side and type for open fractures.

ICD-9 gives you options of one code each for closed and open fractures of the unspecified part of the neck of femur. With ICD-10 implementation, you will need your surgeon to be specific about the side of body, the fracture occured. In addition, for open fractures, which are incredibly rare at the hip, your surgeon will also need to confirm the type of the fracture. Use this ICD-10 walkthrough to assist you in assigning the correct femoral neck code, prior to the Oct. 2014 implementation deadline.

In ICD-10: You will turn to category S72.00 for an unspecified fracture of the femoral neck. In this category of codes, there are 6th and 7th digits further which help you to select a code based on laterality and stage of encounter. A 6th digit is required to specify whether it is a fracture of the right (1) or left (2) femur or if unspecified (9).  If bilateral, the code would be reported twice.  And lastly a 7th digit is required to specify the stage of the encounter -- initial, subsequent with routine healing vs. delayed healing vs. nonunion vs. malunion, and sequelae, says Ruby O'Brochta-Woodward, BSN, CPC, CCS-P, COSC, ACS-OR, compliance and research specialist, Twin Cities Orthopedics, P.A. 

If both femurs are fractured, you would not be reporting the same code twice; you would be reporting two different codes. The 6th digit would be '1' for an unspecified fracture of the neck of the right femur while for the left femur it would be '2', says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, Coder on Call, Inc., Milltown, New Jersey and orthopedic coding division director, The Coding Network, LLC, Beverly Hills, CA.

7^th Digit Classification Has an Impact

This 7th digit classification transforms the reporting of femur fractures in ICD-10. The 7th digit classification will remove the follow up V codes, the 900 series late effect codes, the 733.81 (Malunion of fracture) and 733.82 (Nonunion of fracture) for nonunion and malunion and will give you the ability to code for a delayed union, says Woodward.  In ICD-9, there are options for follow up visits, nonunion, malunion, and sequelae but these are more generic codes and are not directly tied to the specific fracture type.  There is currently no coding option for a delayed healing.

Confirm Side for Closed Fractures

When you report for a femoral neck fracture where your surgeon does not specify which part of the femoral neck was fractured, you report code 820.8 (Fracture of unspecified part of neck of femur closed) in ICD-9. With the implementation of ICD-10 in 2014, you will need to specifically report if the fracture was on the right or the left side.

Make sure your surgeon documents the side for a closed fracture of the unspecified part of neck of femur. Depending upon whether it was a right or left sided fracture, you report code S72.001A (Fracture of unspecified part of neck of right femur, initial encounter for closed fracture) or S72.002A (Fracture of unspecified part of neck of left femur, initial encounter for closed fracture). ICD-10 calls for extensive documentation. The differences between fracture diagnosis reporting in ICD-9 and ICD-10 demand comprehensive physician education as few documents support the level of detail demanded for fracture code assignment in ICD-10, says Stout.

If however, your surgeon fails to document the side for the fracture of the unspecified part of the neck of femur, you will report code S72.009A (Fracture of unspecified part of neck of unspecified femur, initial encounter for closed fracture). This is not to be a recommended option, and you should train your surgeons to specify the side, as this will be a possible method for insurance denials, says Bill Mallon, MD, former medical director, Triangle Orthopedic Associates, Durham, N.C.

Look At Side and Type for Open Fractures

When reporting an open fracture of an unspecified part of the femoral neck, you report code 820.9 (Fracture of unspecified part of neck of femur open). When ICD-10 goes effective, you will select the right code depending upon not only the side but also the type of fracture (Table 1). The ICD-10 scenario for an unspecified open fracture of the femoral neck will be very similar to that for the closed fracture, says Woodward. The 6th digit option will be the same for the open as the closed fracture, specifying laterality.  The 7th digit will include the same options as those for the closed fracture however the classification of the open fracture using the Gustillo classification will also be required for each stage of the encounter except the sequelae.  In ICD-9, the coder has only one code option, 820.9.

Reporting codes such as 820.9 that include the word 'unspecified' as part of their definition are starting to draw denials as payers seek greater specificity in physician reporting before they will pay a claim, says Stout.

If however, your surgeon fails to document the side of the open fracture of unspecified part of neck of femur, you will report code S72.009B (Fracture of unspecified part of neck of unspecified femur, initial encounter for open fracture type I or II) for type I and II fractures and code S72.009C (Fracture of unspecified part of neck of unspecified femur, initial encounter for open fracture type IIIA, IIIB, or IIIC) for type III fractures.

Make sure you have complete documentation. It will be imperative for the provider to document laterality, whether the visit is an initial or follow up visit, and if there are any complications related to the fracture, says Woodward.  If the current problem is a result of a previous fracture (i.e. sequelae of the fracture), it will be imperative for the provider to document that as well as the specifics of the fracture type.  Additionally, they will need to document the open classification of the fracture and not merely document that it is an open fracture.