Radiology Coding Alert

Sometimes, the index yields surprising results.

Every once in a while, you come across a diagnosis that you can seemingly only scratch your head at. During these moments of helplessness, don’t despair. There’s always a method to determining the correct ICD-10 code, even when using the index doesn’t work in your favor.

Take a look at this challenging example to help prove the point that there is no diagnostic equation that’s unsolvable.

Take Combination Diagnoses One Step at a Time

Example: Intraarticular tibial plateau fracture complicated by lipohemarthrosis of the right knee.

There are numerous different diagnostic variables at play here. First, you’ve got to determine how many diagnosis codes are needed given the patient’s condition. Typically, you’d be correct in assuming that any symptoms resulting from a fracture should be left out of the diagnostic coding equation. However, this example proves slightly more challenging due to the phrasing of “complicated by.” However, before determining what diagnoses are not worthy of submission, you need a firm understanding of what lipohemarthrosis actually is.

After quickly realizing that lipohemarthrosis is a non-indexable term, your best bet may be to attempt to break the term down by its affixes and root word. First, you’ve got the prefix “lipo,” which translates to “fat.” Next, you’ll find that the prefix “hem” is an alternative form of “hemo,” which translates to “blood.” To round out this complex term, you will combine the root word “arthro” (joint) and suffix “osis” (condition). Using this formula, you can conclude that lipohemoarthrosis of the knee is a condition of the joint involving blood and fat. However, this doesn’t necessarily get you any closer to determining the correct diagnosis code.

Choose Your Online References Carefully

While you may find plenty of Google sources offering insights into what sort of condition lipohemarthrosis is, the majority of them should not be considered definitive, expert sources. For instance, the first result, Radiopaedia, is actually an open-content webpage in which articles are formed through a collaborative effort of the community. These sorts of sources, such as Wikipedia, should not be considered definitive authorities on a subject.

Rather, if you are going to rely on a web search for an answer, stick to well-established organizations such as the Centers for Medicare and Medicaid Services (CMS) or the American College of Radiology (ACR). Additionally, you may also rely on peer-reviewed studies from established, peer-reviewed journals. Using this last option, you may come across an article from the Journal of Clinical Imaging Science, which defines lipohemarthrosis as the following:

• “Lipohemarthrosis is defined as the presence of intracapsular floating fat in a joint cavity. Traumatic knee injury represents the most common cause, and lipohemarthrosis is widely considered pathognomonic for acute fracture.”

Decide Between Single, Multiple Diagnoses

You’re now able to see a clearer diagnostic picture of these two interrelated conditions. Despite the fact that the lipohemarthrosis is clearly a result of the fracture, you should conclude that it’s a necessary diagnosis due to the “complication” factor. If you were dealing with a more “typical” symptom of a tibial plateau fracture (hematoma, bony fragments), then the fracture would be the only necessary diagnosis.

You are now tasked with properly coding both conditions. While coding a tibial plateau fracture is relatively simple, some coders might get hung up on the “intraarticular” adjective.

“An intraarticular tibial plateau fracture is one that extends to the cortex of the tibial plateau that forms the inferior aspect of the knee joint,” says Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. “In other words, it’s a fracture through the bone, extending into the inferior aspect of the joint,” Rosenberg explains.

So, unless the intraarticular fracture extends to another portion of the joint, such as the patella, you may disregard the intraarticular descriptor and code exclusively as a tibia plateau fracture. While there is no designated diagnosis for tibia plateau fracture, there is a code for fracture of the upper end of the right tibia. Therefore, you should report code S82.101A (Unspecified fracture of upper end of right tibia, initial encounter for closed fracture).

Note: Do not report S82.191A (Other fracture of upper end of right tibia, initial encounter for closed fracture) for a tibia plateau fracture unless the provider documents a specific type of fracture. The descriptor “plateau” references the location (upper end), not type of fracture.

Don’t Get Hung Up on Nonessential Modifiers

Next, you’ve got to come up with a diagnosis for lipohemarthrosis. While you cannot find lipohemarthrosis in the ICD-10 index, you can find hemarthrosis. However, some coders may get hung up while doing so. Next to hemarthrosis, you will find the word “nontraumatic” in parentheses. For coders without a fundamental understanding of the ICD-10 guidelines, they may conclude that this code is incorrect due to the traumatic nature of the patient’s condition.

However, coders must know that any term listed in parentheses is known as a nonessential modifier. The ICD-10 guidelines state the following regarding nonessential modifiers:

• “Parentheses are used in both the Alphabetic Index and Tabular List to enclose supplementary words that may be present or absent in the statement of a disease or procedure without affecting the code number to which it is assigned. The terms within the parentheses are referred to as nonessential modifiers.”

With these guidelines in place, coders should feel comfortable disregarding the nonessential modifier next to hemarthrosis since it does not apply to the patient’s condition. “Make sure to refer to Hemarthrosis ⇒ traumatic rather than Hemarthrosis ⇒ knee,” relays Lindsay Della Vella, COC, medical coding auditor at Precision Healthcare Management in Media, Pennsylvania. “Hemarthrosis ⇒ traumatic will then lead you to see ‘Sprain, by site,’ where you will wind up at code S83.91XA (Sprain of unspecified site of right knee, initial encounter),” Della Vella explains. This is a valuable example of when the ICD-10 index can lead you to a code that you may have never envisioned given the underlying diagnosis.