Orthopedic Coding Alert

Warning: One documentation slip could lead to a $216 mistake Ignore the number of fracture fragments in a wrist report, and you could be setting yourself up for audit trouble. But that's not all. Matching codes and modifiers to your surgeon's documentation means catching every clue, whether noting an assistant surgeon or keeping open fractures separate from open treatment. Hone your skills: Try your hand at this real-life op report excerpt, and then check your answers below. Hint: Pay attention to the assistant surgeon's role to ensure accurate modifier choices, says Susan Vogelberger, CPC, CPC-H, CPC-I, CMBS, CCP, president of Healthcare Consulting and Coding Education in Boardman, Ohio. And assume that you are not reporting any imaging services for the surgeon. Analyze the Op Report Pre- and postoperative diagnosis: Multifragmented intra-articular (two fragments) fracture of the distal radius, right wrist Procedure performed: Open reduction internal fixation of multifragmented intra-articular (two fragments) fracture of the distal radius, right wrist Description excerpt: This was a very difficult fracture with a tremendous displacement and also intra-articular components, and the operation could not be done without the assistance of my first assistant - A traction apparatus was applied to the hand, and maneuvering was performed by me and my assistant to reduce the fracture. Once the fracture was reduced, there was a very large dorsal defect that was filled with bone allograft. The bone allograft has been reconstituted previously. Then a Locon-T plate was used and bent to fit the fracture fragments, especially in the distal part of the fracture. The x-rays were obtained to make sure that the plate was in good position, and it was adequately shaped. Once we identified that it was, multiple screws were applied following the manufacturer's technique. X-rays were obtained throughout to make sure that the screws were in good position and were of good length. AP and lateral x-rays show that the screws were in excellent position. One of the screws was a little long and had to be replaced. Nevertheless, the reduction of the fracture was excellent. Choose Proper Distal Radius Diagnosis Start from the top: Based on this documentation, you should report 813.42 (Fracture of radius and ulna; lower end, closed; other fracture of distal end of radius [alone]) as the diagnosis, Vogelberger says. Closed code clue: The documentation doesn't specify whether the distal radius fracture is open or closed, but the AHA's Coding Clinic advises you to report a closed fracture code, such as 813.42, if documentation doesn't indicate closed or open. And remember that you shouldn't assume you should report an open fracture code (such as 813.5x, - lower end, open) when the surgeon performs an open reduction -- or a closed fracture [...]