Orthopedic Coding Alert

Coding for late effects of traumatic injuries is often poorly understood. When incomplete diagnostic information is passed on from surgeon to coder, the result can be a denied claim due to inaccurate reporting of the condition(s) being treated and a missed opportunity for legitimate reimbursement.

What Are They?

Late effects are long-term effects of, or conditions produced by, an injury or illness after the acute phase has resolved. Some late effects present early, while others might present months or years later. The codes (905.0-909.9) that define causes of late effects can be found under the heading Late Effects of Injuries, Poisonings, Toxic Effects, and Other External Causes'' in the ICD-9 manual. Those most commonly used in orthopedics include:
 

905.0-905.5 late effect of fracture

905.6 late effect of dislocation

905.7 late effect of sprain and strain without mention of tendon injury

905.8 late effect of tendon injury

905.9 late effect of traumatic amputation

906.0-906.9 late effects of injuries to skin and subcutaneous tissues.  

Common Code Pairings for Orthopedics

When reporting conditions that are late effects of an acute injury, the primary diagnosis should be the residual problem/condition and the secondary diagnosis will be the late effects code. For example, 729.6 (residual foreign body in soft tissue) is the primary code and is paired with 906.1 (late effect of open wound of extremities without mention of tendon injury) as the secondary code.
 
Common orthopedic conditions that are always the late effect of an injury include:
 

733.81 malunion of fracture

733.82 nonunion of fracture.
 
One of these codes would be sequenced first with the appropriate late effects code listed second. For example, a nonunion of the scaphoid is reported with 733.82 and 905.2 (late effect of fracture of upper extremities).
 
Code 718.8x (other joint derangement, not elsewhere classifiable) is often the late effect of a dislocation or sprain.
 
The following codes are often paired with the late effect of fracture codes (905.0-905.5): 997.6-997.69 (amputation stump complication) could be paired with 905.9 (late effect of traumatic amputation); 996.4 (mechanical complication of internal orthopedic device, implant and graft); 996.67 (infection and inflammatory reaction due to other internal orthopedic device, implant and graft); 996.78 (other complications due to other internal orthopedic device, implant and graft).
 
Code 730.1x (chronic osteomyelitis) can be the late effect of a traumatic bone injury (most likely an open fracture). 

Why Late Effects Matter

If a patient seeks treatment well after an accidental injury that occurred at work, and the carrier receives a claim with an acute injury diagnosis (like a fracture that was treated and healed), it may deny the claim under the assumption that the patient has suffered a new acute injury. The carrier may also deny it due to lack of medical necessity. In other words, the claims adjuster will likely ask, ""Why would a patient need treatment for a fracture that occurred two years ago?""
 
However, if the doctor correctly indicates that the patient has post-traumatic arthritis of the ankle as a late effect of his original ankle fracture, the carrier receives information that establishes the relationship between current treatment and the old injury. This becomes important when further surgery is needed, in this case, perhaps a debridement of the ankle joint (29897 or 29898) or ultimately an ankle fusion (27870, arthrodesis, ankle, any method). When a patient has an injury that is several years old, late effect codes make the connection between the residual condition(s) currently requiring treatment and the initial injury in his notes.
  
For example, a patient who is years out from an injury may present with ankle pain related to an old fracture. ""A lot of the time,"" says Heidi Stout, CPC, CCS-P, coding and reimbursement manager at University Orthopedic Associates in New Brunswick, N.J., ""the physician will record the original injury diagnosis, perhaps 824.9 (fracture of ankle, unspecified, open) as the reason for the encounter."" Stout says this is incorrect. ""The fracture healed long ago."" Review of the office note reveals that the patient has post-traumatic arthritis as a late effect of the fracture, correctly reported as 716.17 (traumatic arthropathy; ankle and foot) and 905.4 (late effect of fracture of lower extremities).
 
A second example is a patient who suffered a traumatic partial amputation of the left thumb (26951, amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure) two years prior and returns to the orthopedic surgeon who initially cared for him with a complaint of pain and swelling of the amputation stump. The surgeon records the diagnosis, ""status post amputation, left thumb"" on the encounter form, which might lead a coder to incorrectly select diagnosis codes that would indicate routine follow up of a healed injury, V67.09 (following other surgery) and V49.61 (thumb). In reviewing the documentation, the coder notes that the surgeon has recommended surgery to remove a neuroma. The correct diagnoses codes for the encounter are 997.61 (neuroma of amputation stump) and 905.9 (late effect of traumatic amputation).
 
Other than simply being correct coding practice, late effects tell the whole story, and present a much clearer picture to the carrier of what is going on and why. Terry Fletcher, BS, CPC, CCS-P, an independent coding and reimbursement specialist in Dana Point, Calif., explains that late effects codes (905.0-909.9) link what is going on with the patient now with what happened in the past. ""Like E codes for external causes of injury and poisoning, late effects codes can become an issue for patients who are injured in an auto accident or in workers' compensation claims,'' Fletcher says.