Radiology Coding Alert

Hint: nonunion means non-healing.

You see your share of fracture cases in your workflow. Are you prepared for encounters where the patient has delayed seeking treatment, experienced incorrect healing of the fracture, or if the injury isn’t healing at all?

Radiology Coding Alert has sifted through the guidelines to help you identify the correct 7th characters for your fracture codes.

Examine This Arm Fracture Scenario

Scenario: A patient presents to your outpatient radiology practice with a complaint of right arm pain. The patient experienced a traumatic closed oblique displaced fracture of the right humeral shaft six months earlier. At the time of the injury, the provider performed a closed manipulation and wrapped the patient’s arm in a fiberglass cast. During this encounter, the radiologist captures anteroposterior (AP) and lateral X-ray views of the right arm, interprets the results, and writes their report. The patient is diagnosed with a closed oblique displaced fracture malunion of the right humeral shaft.

With a quick search of the ICD-10-CM Alphabetic Index and verification in the Tabular List, you’ll locate the diagnosis code for the patient’s injury. Code S42.331- (Displaced oblique fracture of shaft of humerus, right arm) fulfills the first six characters of the code, but you’ll notice this code carries a 7th character required icon. Your 7th character choice will designate the encounter as initial treatment, subsequent treatment, or a late effect caused by the injury.

A note listed under parent code S42.- (Fracture of shoulder and upper arm) lists the appropriate 7th character options that apply to the codes in this category. However, not all of the characters apply to the above scenario.

“The difference between these 7th character options lies in the type of fracture the patient has. Was it an open fracture? Was it a closed fracture? This will be a great starting point,” says Chelsea Kemp, RHIA, CCS, COC, CPC, CPCO, CDEO, CPMA, CRC, CCC, CEDC, CGIC, AAPC Approved Instructor, outpatient coding educator/auditor at Yale New Haven Health in New Haven, Connecticut.

When you review the scenario, you’ll notice the patient experienced a closed fracture and the fracture has healed incorrectly. “Malunion is a fracture that is healed, but it healed in the incorrect position. Nonunion is a fracture that is not healing at all,” Kemp adds.

With this information in mind, you’ll look at the following 7th character options:

• A - Initial encounter for closed fracture
• P - Subsequent encounter for fracture with malunion

Here’s why: “Traumatic fractures are coded using the appropriate 7th character for initial encounter (A, B, C) for each encounter where the patient is receiving active treatment for the fracture,” according to the ICD-10-CM Official Guidelines, Section I.C.19.c.1. On the flip side, you’ll use a different 7th character to specify subsequent care, as the guidelines tell you “Fractures are coded using the appropriate 7th character for subsequent care for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase.”

If you examined the scenario above based on these two guidelines, you might postulate that the patient is seeking active treatment for the injury, which would warrant 7th character A. However, if you read two paragraphs further into the guidelines, you’ll find the answer you’re seeking.

The guidelines continue to explain “Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7th character for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R).”

Based on this last guideline, you’ll use S42.331P (Displaced oblique fracture of shaft of humerus, right arm, subsequent encounter for fracture with malunion) with 7th character P to report the scenario above.

Decide How to Report Delayed Care

Now that you understand how to correctly report an encounter where the patient is seeking care for nonunion or malunion of a fracture following active treatment, you may have medical reports where the patient waited to seek treatment for a fracture’s malunion or nonunion.

Scenario: A patient presents to your outpatient radiology practice with a complaint of upper left leg pain. About eight months ago, the patient was diagnosed with a traumatic closed oblique displaced fracture of the left femur, but they chose not to seek treatment at the time of diagnosis. During the current encounter, the radiologist captures two-view X-rays of the left femur and reports that the femur has now formed a malunion, which will require surgery to repair the injury. The patient is diagnosed with a closed oblique displaced fracture of the left femur.

For this scenario, ICD-10-CM Official Guidelines, Section I.C.19.c.1 tells you “the appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.”

Since the guidelines don’t include a specific definition of delaying seeking treatment, you will treat the encounter as if the patient is seeking active treatment for the injury. “If a patient delays in seeking initial treatment for a fracture and it results in a nonunion or malunion, the appropriate 7th character for active care of the fracture is A,” Kemp explains. Kemp adds that knowing the patient’s history and when active treatment occurred are essential for correct 7th character assignment.

For this scenario, you’ll assign S72.332A (Displaced oblique fracture of shaft of left femur, initial encounter for closed fracture) to report this diagnosis, rather than S72.332P (… subsequent encounter for closed fracture with malunion).

Pay Attention to Delayed Documentation

The guidelines include phrasing regarding patients who “delayed seeking treatment,” and 7th characters G, H, and J, are designated for subsequent encounters for fractures “with delayed healing,” but the two phrases cannot be used interchangeably.

When a patient delays seeking treatment, they are putting off surgery, reduction, or another treatment option until a later time, whereas if the patient experiences delayed healing of a fracture, the injury is taking longer than usual to heal.

“Be careful not to confuse ‘delay’ in seeking treatment, with ‘delayed healing’. The delayed healing 7th character options are much different than a situation where a patient delayed in seeking treatment for the initial fracture and it resulted in a nonunion or malunion of the fracture,” Kemp says.