Podiatry Coding & Billing Alert

Report 7^th character "A" as long as the patient receiving active treatment for fracture.

Although coding for fractures may be one of the most challenging tasks you encounter in your coding career, you don't have to let this potential pitfall trip youup. One important piece of information you absolutely must know is whetherthe fracture is traumatic or pathological because this factor will dictate your ICD-10 choices.

Heed the following handy tips to protect fracture reimbursement in your podiatry practice.

Tip 1: Define Pathological Fractures for Complete Coding Clarity

A pathologic fracture occurs when a bone breaks in an area that is weakened by another disease process. Causes of weakened bone include tumors, infection, and certain inherited bone disorders. There are dozens of diseases and conditions that can lead to a pathologic fracture or dislocations, says Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, CPC, CPMA, CAC, CCS-P, CHC, chief executive officer of Edelberg+Associates in Baton Rouge, Louisiana.

A pathologic fracture or dislocation usually occurs with normal activities - patients may be doing very routine activities when their bone suddenly fractures or dislocates. The reason for a fracture is that the underlying disease process weakens the bone to the point where the bone is unable to perform its normal function, Edelberg explains.

For example, a bone cyst may grow to a significant size where the tumor effectively eats away a significant portion of normal bone. This area of bone is now much weaker, and prone to pathologic fracture.  

Don't miss: "Any patient who experiences a fracture without a traumatic injury that would normally cause the bone to break, such as a fall or a motor vehicle accident, should be suspected to have a pathologic fracture," says M. Dolores Farrer, DPM, MBA, wound care consultant and owner of Owner of Lagniappe Wound Care Consultants, LLC in Columbia, South Carolina. "If the patient's fracture is pathological in nature, the doctor will also want to diagnosis the reason the bones are weak and treat the underlying disease."

Although pathologic fractures are from weak bones, in many cases it doesn't affect normal bone healing, Farrer adds. It's easy to think of this occurring in the elderly, but unfortunately if it occurs in the pediatric population, it may be an indication of an active bone tumor.

Tip 2: Mind Which 7^th Character You Choose

When it comes to pathological fractures, you must choose the appropriate seventh character, which indicated the level of encounter. If that information is not in the podiatrist's record, so you may need to contact them to verify what to list as the code's seventh character.

The guidelines offer specific instructions about when to use the seventh characters A (Initial encounter for fracture) and D (Subsequent encounter for fracture with routine healing) as well as general instructions for proper use of the other seventh characters.

A: You would report the seventh character "A" as long as the patient is receiving active treatment for the fracture, per the ICD-10-CM Official Guidelines for Coding and Reporting.

Don't miss: New or different physicians could manage the care of the patient's pathological fracture over the course of the treatment. However, the seventh character of the fracture codes is based upon whether the patient is undergoing active treatment - not whether the physician is seeing the patient for the first time.

D: You would use the seventh character "D" for encounters after the patient has completed active treatment for the fracture and is receiving routine care for the fracture during the healing or recovery phase.

Other 7th characters: You would use the other characters, which you can find under each pathological fracture subcategory in the Tabular List, for subsequent encounters that treat problems associated with the fracture's healing - malunions, nonunions, and sequelae.

Tip 3: Notice if Fracture is Due to Osteoporosis

One of the pathological fracture categories in ICD-10 is due to osteoporosis, which is found in categories M80.0- (Age-related osteoporosis with current pathological fracture) and M80.8- (Other osteoporosis with current pathological fracture).

Osteoporosis defined: The guidelines identify osteoporosis as "a systemic condition, meaning that all bones of the musculoskeletal system are affected."

You should only report codes from category M80- (Osteoporosis with current pathological fracture) for patients who have a current pathologic fracture at the time of the encounter, per the guidelines. The codes in this category identify the site of the patient's fracture.

Caution: You should report a code from category M80-, not a traumatic fracture code, if a patient with known osteoporosis has a fracture. This is true even if the patient has a minor fall or trauma - but only if that fall or trauma would not have usually broken a normal, healthy bone.

Tip 4: Mark Down Category M84.6-

Another pathological fracture category is due to other specified disease, which is found in category M84.6- (Pathological fracture in other disease).

Some examples of "other diseases" that could cause pathological fractures include osteogenesis imperfecta, bone cysts, fibrous dysplasia, Paget's disease, osteomyelitis, and histiocytosis, according to Ruby Woodward, BSN, CPC, CPMA, CPB, COSC, CSFAC, CPC-I, coding and compliance manager at Suburban Imaging/Suburban Radiologic Consultants in Minneapolis, Minnesota.

Documentation details: When it comes to documentation details you should look for when reporting pathological fractures due to "other specified disease," look to this advice from Woodward.

"I would want to see documentation of an underlying pathology, as well as a specific diagnosis stating the pathologic fracture," Woodward explains. "If there is an underlying disease and no documentation of trauma sufficient to produce a fracture, but no documentation of it being pathologic, I would query the physician."