Orthopedic Coding Alert

Question: Encounter notes indicate that the provider performed a level-three evaluation and management (E/M) service for an established patient with a “March fracture/arm.” How do I report this encounter?

Indiana Subscriber

Answer: The E/M is easy enough; report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.). Things get more nebulous for the diagnosis code, however.

A march fracture is the same as a stress fracture. Other terms that are considered synonymous with stress fracture are fatigue fracture, stress fracture NOS, or stress reaction. Your root ICD-10 code for this condition is M84.3- (Stress fracture). You cannot stop there, though.

Why? These diagnosis codes go to the 7th character, so you’ve got three more characters to fill out in order to complete this diagnosis.

Do this: Go back and check the notes, and try to find out:

• What part of the arm has the March fracture?
• On which side of the body is the March fracture?
• What type of encounter is this for the March fracture (initial, subsequent, sequela, etc.)?

Then, you can go back and choose from the following codes:

• M84.321- (Stress fracture, right humerus)
• M84.322- (Stress fracture, left humerus)
• M84.329- (Stress fracture, unspecified humerus)
• M84.331- (Stress fracture, right ulna)
• M84.332- (Stress fracture, left ulna)
• M84.333- (Stress fracture, right radius)
• M84.334- (Stress fracture, left radius)
• M84.339- (Stress fracture, unspecified ulna and radius)

Then, you can choose from the following 7th characters to complete your diagnosis:

• A = Initial encounter for fracture
• D = Subsequent encounter for fracture with routine healing
• G = Subsequent encounter for fracture with delayed healing
• K = Subsequent encounter for fracture with nonunion
• P = Subsequent encounter for fracture with malunion
• S = Sequela.