Otolaryngology Coding Alert

Question: Is an open or closed fracture the same thing as open and closed treatment?

South Carolina Subscriber

Answer: No, the terms "fracture" and "treatment" refer to ICD-9 and CPT coding respectively and are not interchangeable. An open or closed fracture refers to the type of wound, but an open or closed treatment refers to the surgical procedure the physician uses to fix the fracture.

ICD-9's fracture figure defines an open fracture as "skin broken." Basically, if the skin is broken, the wound is open and you should report an open diagnosis code. For instance, a patient presents with a nasal fracture in which the bone is poking through the skin. In this case, because the skin is broken, you should report an open wound (802.1, Fracture of face bones; nasal bones open). On the other hand, if the skin is intact, the fracture is closed (802.0, nasal bones, closed). When the doctor does not indicate whether the wound is open or closed, ICD-9 indicates to code a closed fracture.

In contrast, treatment refers to the method the surgeon uses to fix the fracture. "Closed treatment specifically means that the fracture site is not surgically opened," according to CPT. You should report open treatment when the surgeon opens the fracture bone and uses internal fixation or opens the fractured bone remotely to insert an intramedullary nail across the fracture site. If, for example, the otolaryngologist places forceps into the nose to realign the nasal bones, a procedure which does not require surgically opening the nose, you should report closed treatment with manipulation (21315*, Closed treatment of nasal bone fracture; without stabilization). But when the closed manipulation fails, the surgeon may have to perform open reduction, a procedure in which the otolaryngologist surgically exposes the fracture site and manipulates the fragments into proper alignment under direct vision. In this case, you should report an open treatment (21325, Open treatment of nasal fracture; uncomplicated).

These examples illustrate that the diagnosis and treatment do not have to match. "The type of fracture (e.g., open, compound or closed) does not have any coding correlation with the type of treatment (e.g., closed, open, or percutaneous) provided," CPT states.

Answers to You Be the Coder and Reader Questions provided by Pamela J. Biffle, CPC, CCS-P, an independent consultant in the Dallas/Fort Worth area and approved professional medical coding curriculum instructor; Barbara Cobuzzi, MBA, CPC,     CPC-H, an otolaryngology coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J.; and Tara R. Ritter, appeals coordinator for American Physician Services, which serves multiple ENT, allergy, sinus and head and neck practices in metro Atlanta.