Podiatry Coding & Billing Alert

Hint: Traumatic fractures are caused by trauma.

Fractures can be really difficult to code because ICD-10-CM offers so many different options, all based on specificity. You must always carefully read the medical documentation to choose the appropriate fracture code for your claim.

Read on to learn how to distinguish between three types of fractures: pathological, traumatic, and stress.

Type 1: Understand What Causes Pathological Fractures

Pathological fractures are caused by disease, such as osteoporosis or neoplastic disease. The disease process weakens the bone, it is not able to perform as normal, and it breaks. Oftentimes a patient will get a pathological fracture while participating in everyday activities.

Coding tip: Always read the documentation to find the underlying cause of the disease.

ICD-10-CM codes for pathological fractures: ICD-10-CM has three pathologic fracture categories — due to neoplastic disease, due to osteoporosis. and due to other specified disease. You may encounter the following types of pathological fractures in your podiatry practice. (Note: This is not an exhaustive list):

• M80.071A (Age-related osteoporosis with current pathological fracture, right ankle and foot, initial encounter for fracture) through M80.071S (Age-related osteoporosis with current pathological fracture, right ankle and foot, sequela)
• M80.072A (Age-related osteoporosis with current pathological fracture, left ankle and foot, initial encounter for fracture) through M80.072S (Age-related osteoporosis with current pathological fracture, left ankle and foot, sequela)
• M80.871A (Other osteoporosis with current pathological fracture, right ankle and foot, initial encounter for fracture) through M80.871S (Other osteoporosis with current pathological fracture, right ankle and foot, sequela)
• M84.471A (Pathological fracture, right ankle, initial encounter for fracture) through M84.471S (Pathological fracture, right ankle, sequela)
• M84.571A (Pathological fracture in neoplastic disease, right ankle, initial encounter for fracture) through M84.571S (Pathological fracture in neoplastic disease, right ankle, sequela)
• M84.671A (Pathological fracture in other disease, right ankle, initial encounter for fracture) through M84.671S (Pathological fracture in other disease, right ankle, sequela).

Example: The patient, who has neoplastic disease, suffers from a current pathological fracture of their right ankle. This is an initial encounter. The podiatrist documents that the underlying neoplasm is a malignant neoplasm of the short bones of the right lower limb. You should report M84.571A for the pathological fracture and C40.31 (Malignant neoplasm of short bones of right lower limb) for the neoplasm.

Fracture coding tip: “Even though non-operative, non-manipulative fracture care services are not surgical, they carry a 90-day global period,” says Jeri L Jordan, CPC, billing manager at Hampton Roads Foot and Ankle in Williamsburg, Virginia. “If you are billing an office visit on the same day, you would need to modifier 57 [Decision for surgery] on your claim. Follow-up visits must also adhere to the global period rules.”

Type 2: Observe Codes for Traumatic Fractures

On the other hand, traumatic fractures are caused by trauma such as an accident, fall, or other kind of force, such as when a heavy object strikes a patient. For traumatic fractures for podiatry patients, you should look to the following codes:

• S82- (Fracture of lower leg, including ankle)
• S92.0- (Fracture of calcaneus). Note: This includes the heel bone and os calcis.
• S92.1- (Fracture of talus). Note: This includes the astragalus.
• S92.3- (Fracture of metatarsal bone(s))
• S92.4- (Fracture of great toe)
• S92.5- (Fracture of lesser toe(s))
• S92.8- (Other fracture of foot, except ankle)

Documentation details: When it comes to traumatic fractures, you must check for important details in the documentation including whether the fracture is closed or open.

Closed fractures involve a bone break that has not penetrated the skin. 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. On the other hand, open fractures occurs when the bone has punctured the skin or there is a significant break in the skin directly over the fracture site — not an abrasion or superficial laceration.

Coding tip: If the medical documentation does not specify whether the traumatic fracture is open or closed, you should report it as closed, according to the ICD-10-CM Official Guidelines for Coding and Reporting.

To choose the appropriate code for the traumatic fracture, you must also know if it is displaced or nondisplaced. In a displaced fracture, the bone snaps in two or more places and moves so that the two ends are not in their normal alignment. In a non-displaced fracture, the bone cracks either part or all the way through, but it maintains its proper alignment and has not moved from its normal position.

Coding tip: If the documentation does not indicate if his traumatic fracture is displaced or nondisplaced, code it as displaced, per the guidelines.

Example: The patient, who was recently injured in a car accident, sustained a nondisplaced fracture of the medial malleolus of their left tibia. This was an initial encounter for a closed fracture.

Solution: Report S82.55XA (Nondisplaced fracture of medial malleolus of left tibia, initial encounter for closed fracture) on your claim. A medial malleolus fracture is a fracture of the inner side of the ankle at the end of the tibia.

Type 3: Focus on Options for Stress Fractures

Unlike pathological and traumatic fractures, stress fractures are tiny cracks in the bone caused by repetitive stress or force, often from overuse. Stress fractures often occur in normal or metabolically weakened bones. Patients may have a stress fracture without even realizing it. When a patient has a stress fracture, they usually complain of pain that is nagging or gradually building.

Coding tip: The ICD-10 manual tells you to report an additional external cause code to identify the cause of the stress fracture.

You should look to the following codes to report stress fractures of the foot:

• M84.371- (Stress fracture, right ankle)
• M84.372- (Stress fracture, left ankle)
• M84.374- (Stress fracture, right foot)
• M84.375- (Stress fracture, left foot)
• M84.377- (Stress fracture, right toe(s))
• M84.378- (Stress fracture, left toe(s))

Example: The podiatrist diagnoses the patient with a stress fracture in his left foot. This is an initial encounter. You should report code M84.375A (Stress fracture, left foot, initial encounter for fracture) on your claim.