Outpatient Facility Coding Alert

Aggregate all your chapter-specific fracture coding guidelines into one place.

Most veteran coders typically know how to work their way around a fracture diagnosis. On one hand, coding fractures can be as simple as identifying the type of fracture and assigning the appropriate seventh character. On the other hand, coders often neglect the plethora of guidelines applicable to fractures within the ICD-10-CM manual.

“The ICD-10-CM guidelines offer an extensive array of instructions on fracture coding,” says Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania. “From seventh characters to laterality initial versus subsequent encounters, there’s a lot to digest when it comes to taking in the full scope of ICD-10-CM fracture coding guidelines,” Della Vella explains.

Have a look at each of these core guidelines to maximize your fracture coding accuracy and efficiency.

Properly Sequence Neoplasm-Induced Pathologic Fracture Diagnoses

The ICD-10-CM index has clear and specific instructions for patient encounters involving pathologic fractures and associated neoplasms:

• “When an encounter is for a pathological fracture due to a neoplasm, and the focus of treatment is the fracture, a code from subcategory M84.5- (Pathological fracture in neoplastic disease) should be sequenced first, followed by the code for the neoplasm. If the focus of treatment is the neoplasm with an associated pathological fracture, the neoplasm code should be sequenced first, followed by a code from M84.5 for the pathological fracture.”

As you can see, the main point here comes with the phrasing “focus of treatment.” If the focus of treatment is the neoplastic disease, code the neoplasm as the primary (and possibly, only) diagnosis. If the focus of treatment is the fracture, report the M84.5- code set first followed by the ICD-10 code for the neoplasm.

Note Coding Differences Between Osteoporotic, Traumatic Fractures

Consider these ICD-10-CM instructions when coding a fracture of any patient with known osteoporosis:

• “Category M80- (Osteoporosis with current pathological fracture) is for patients who have a current pathologic fracture at the time of an encounter. The codes under M80 identify the site of the fracture. A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone.”

These coding guidelines are fairly straightforward. If the patient suffers a fracture of an osteoporotic bone, then you should exclusively use a code from the M80- code set. Typically, these fractures will be the secondary result of trauma. If the bone is not identified as osteoporotic, then you should use a code from the S00-S99 code set. You may find that imaging following the injury will identify the fracture as trauma-induced or of an osteoporotic nature. The physician must identify on the dictation report or operative note that the fracture is of an osteoporotic nature in order for you to report code set M80-.

Distinguish Between Complication Codes, Seventh Characters

One important, and often overlooked ICD-10-CM guideline has to do with how you should approach complications of fractures during the postsurgical phase:

• “Care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes. Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate seventh character for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R).”

The codes or seventh character you use to report complications of a fracture repair depend on the nature of the complication. For instance, in order to report nonunion of a displaced fracture of the first right metatarsal bone, use code S92.311K (Displaced fracture of first metatarsal bone, right foot, subsequent encounter for fracture with nonunion). However, if the complication does not involve a problem with healing or union of the fractured bone, you may consider a primary complication code. For instance, if the patient presents with a displaced internal fixation device of the left femur, you will report code T84.125A (Displacement of internal fixation device of left femur, initial encounter).

Refresher: Remember these two fundamental ICD-10-CM fracture coding guidelines on closed/open, displaced/nondisplaced fractures:

• “A fracture not indicated as open or closed should be coded to closed. A fracture not indicated whether displaced or not displaced should be coded to displaced.”

Consider Rules for Delayed Treatment, Gustilo Open Fracture Classifications

ICD-10-CM offers very specific guidelines on how to address a patient who presents for delayed treatment of a fracture:

• “The appropriate seventh character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.”

As these instructions suggest, a patient who presents for imaging or treatment in the months following a fracture, and the healing process results in nonunion or malunion, you should refrain from coding with seventh characters K (nonunion) or P (malunion). Instead, you will report the fracture with seventh character A (initial encounter). This can be difficult to discern depending on the documentation of the imaging or operative report. If the provider fails to identify the age of the fracture, you should code under the assumption that the fracture is of an acute nature.

Finally, take a look at the ICD-10-CM guidelines on the Gustilo open fracture classifications:

• “The open fracture designations in the assignment of the 7th character for fractures of the forearm, femur and lower leg, including ankle are based on the Gustilo open fracture classification. When the Gustilo classification type is not specified for an open fracture, the 7th character for open fracture type I or II should be assigned (B, E, H, M, Q).”

“Gustilo classification of fractures qualifies the risks associated with long bone fractures, based on the contamination, and damage to arteries or soft tissue in open fractures,” outlines Sheri Poe Bernard, CPC, of Poe Bernard Consulting in Salt Lake City, Utah. “Type I is the least severe (small, clean wound), and type IIIC is the most severe (requiring arterial reconstruction or repair),” Bernard details.

 

 

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