Orthopedic Coding Alert

There are a variety of treatment options for pediatric femoral shaft fractures, and the patient presenting at the emergency department (ED) further complicates the coding process. Coders must give a complete picture of the situation and the specific services and treatment provided by the orthopedist. The following examples illustrate the complexities involved.

A parent brings a 10-month-old infant to the ED at 11:00 on a Saturday evening. The child is extremely irritable and obviously agitated, and his presentation indicates he is in pain. Earlier on the same day, at 11:00 a.m., a 12-year-old girl was brought to the ED by ambulance. She had fallen off a horse. Her verbal complaints and visible injuries to her right thigh indicated a comminuted femoral fracture. An orthopedic surgeon was called immediately.

Both children will be diagnosed with fractures of the femoral shaft. But beyond that, the cases differ and so does the coding.

Diagnosing and Treating the Infant

The Intervention: The ED physician examines the infant and discovers abdominal trauma and a swollen left thigh with some rotation. Because a displaced femoral fracture is suspected, the ED physician orders a radiograph. Interpretation of the x-ray confirms a fracture of the shaft of the left femur.

The ED physician calls an orthopedist. The orthopedist reviews the interpretation of the x-ray and immediately takes over the care of the infantwhich ultimately results in the orthopedist admitting the patient to the hospital.

When the orthopedist meets with the father of the infant to review treatment plans, the parent says he does not know how the child sustained the injury. But the distraught parent reveals that his wife left him for another man earlier in the day.

The orthopedist documents the family instability on the infants chart but gives first priority to a closed fixation of the femur. Because the abdominal trauma, which is discovered to be limited to cutaneous tissue, precludes immediate spica placement, traction is used to align the split femur until the skin heals. Two days later, a spica cast is employed.

Although the father is instructed in spica cast hygiene, the cast becomes more and more soiled. As an intermediate step at one week, the physician cuts away some of the spica material around the genitals and anus. But at two weeks, a new spica cast must be applied.

During the course of treatment and follow-up, the orthopedist begins to suspect the childs injury was caused by physical abuse. A social worker is called to consult with the father. The father ultimately acknowledges he struck the baby when it would not stop crying and he admits he fears he caused the injury.

Coding: The orthopedist did not interpret the x-ray or [...]