Podiatry Coding & Billing Alert

Check out this expert scenario to see how to code fracture care with manipulation.

Chances are your podiatry practice has set its fair share of broken bones. But, fracture coding can be tricky - especially when it comes to understanding all the particular rules and terminology.

In this first article of a three-part series, you'll learn the nuances of coding for traumatic fractures. For part two, in the next issue, you'll discover more about ankle fractures - including the Gustilo fracture classification system for open fractures. Then, part three will cover the specifics of pathological fractures.

Take a look at these five tips to always submit clean traumatic fracture claims in your podiatry practice.

Tip 1: Understand Difference Between Open and Closed Fracture

A closed fracture involves a bone break that has not penetrated the skin. So, if there is no evidence of a breach of the skin in the encounter notes, you likely have a closed fracture claim on your hands.

Conversely, "an open fracture is when the bone has punctured through the skin or there is a significant break in the skin directly over the fracture site - not an abrasion or superficial laceration," says Sharon Richardson, compliance officer of EM Services at Emergency Groups' Office in San Dimas, California.

Don't miss: If the patient's medical documentation does not specify whether his traumatic fracture is open or closed, you should report it as closed, according to the ICD-10-CM Official Guidelines for Coding and Reporting in Chapter 19, section c.

Tip 2: Watch For Fracture Care With Manipulation

Before you can choose a code, you must determine if the podiatrist performed manipulation before choosing a fracture care code. Examples of fractures that require manipulation include angulated, displaced, and dislocated. If you see any of these terms on the encounter form, be on the lookout for evidence of manipulation.

Example: Consider this detailed clinical scenario from Arnold Beresh, DPM, CPC, CSFAC in West Bloomfield, Michigan,  involving fracture care with manipulation: A patient visits the podiatrist's office for an emergency appointment, stating that he slipped on the icy stairs and caught the front of his foot on the edge of the step. Upon exam, the podiatrist notes that the patient's foot is swollen and tender to the touch over the mid-shaft of the third metatarsal of the left foot. The podiatrist then takes three X-rays that show malalignment of the bone ends. The podiatrist injects the area with local anesthetic and distracts and reduces the metatarsal. The podiatrist then takes X-rays that show the reduction of the fracture. The podiatrist applies a cast and dispenses crutches to the patient with instructions of no weight bearing.

For this encounter, you could report S92.332A (Displaced fracture of third metatarsal bone, left foot, initial encounter for closed fracture) for the diagnosis code and 28475 (Closed treatment of metatarsal fracture; with manipulation, each) for the procedure code.

Tip 3: Don't Let Displaced vs. Not Displaced Trip You Up

If the patient's medical documentation does not indicate if his traumatic fracture is displaced or not displaced, you should code it as displaced, according to the ICD-10-CM Official Guidelines for Coding and Reporting in Chapter 19, section c.

Definition: For a displaced fracture, the bone snaps in two or more places and moves so that the two ends are not in their normal alignment. On the other hand, in a non-displaced fracture, the bone cracks either part or all of the way through, but it maintains its proper alignment and has not moved from its normal position.

Tip 4: Always Choose Correct Seventh Character For Category S92- Codes

For the codes in category S92- (Fracture of foot and toe, except ankle), such as the fifth metatarsal traumatic fracture codes, you must choose a seventh character. This seventh character indicates the type of encounter. For example, your seventh character choices for the initial encounter of fifth metatarsal traumatic fractures are as follows:

• A - initial encounter for closed fracture
• B - ... for open fracture.

For subsequent encounters for fifth fracture metatarsal traumatic fractures, you would turn to:

• D - subsequent encounter for routine healing
• G - ... for delayed healing
• K - ... for non-union
• P - ... for malunion.

And for a sequela, late effects of an injury, you would turn to S - sequela.

Example: If the podiatrist treats an initial encounter for an open, displaced traumatic fracture of the fifth metatarsal bone of the patient's right foot, you could report S92.351B (Displaced fracture of fifth metatarsal bone, right foot, initial encounter for open fracture).

Tip 5: Study These Fracture Complication Terms

As you're considering your seventh character options for fracture codes, you may come across the terms "malunion" and "nonunion," which are two common types of fracture complications.

With a malunion fracture, although the fractured bone heals, it heals in an abnormal position. On the other hand, nonunion occurs when the fractured bone doesn't heal properly - even after an extended recovery period.

The ICD-10-CM Official Guidelines have special rules about how to handle subsequent malunion and nonunion fractures.

Malunion: To specify the subsequent care of a malunion fracture, you will use P, Q, or R as the appropriate seventh character, according to the ICD-10-CM Official Guidelines in Chapter 19, section c, number 1.

Nonunion: To report subsequent care of a nonunion fracture, you will use one of the following seventh characters, according to the ICD-10-CM Official Guidelines in Chapter 19, section c, number 1: K, M, or N.

Editor's note: You will notice that tip four mentions the seventh characters P and K.

The additional characters from the ICD-10-CM Official Guidelines - Q and R for malunion and M and N for nonunion - are part of the Gustilo open fracture classification. The Gustilo fracture classification impacts categories S52- (Fracture of forearm), S72- (Fracture of femur), and S82- (Fracture of lower leg, including ankle). Stay tuned to the next issue to learn more about coding for ankle fractures, including the Gustilo fracture classification.