Radiology Coding Alert

Plus: What to do when the guidelines steer you toward a non-payable code.

When it comes to complex fracture coding, you've got to bring your A-game if you want to make sure you've ended up at the correct diagnosis code. While both experience and a fundamental knowledge of anatomy come into play when coding pathologic and traumatic fractures, it's also important that each coder takes the time to understand each ICD-10-CM guideline at play for these various conditions.

However, as coders who have adequately reviewed the ICD-10-CM guidelines know, these guidelines are not centralized in one specific section or chapter. Instead, you've got to maneuver between various segments of the ICD-10-CM in order to get a comprehensive list of fracture coding guidelines.

Whether you're still in the learning process, or simply in need of a refresher, keep reading for a full breakdown of all the crucial guidelines necessary to code any fracture-oriented scenario.

Rely on Focus of Treatment for Pathologic Fx, Neoplasms

Radiologists will occasionally report on patients with pathologic spinal fractures due to a neoplasm, either malignant or benign. Since most primary malignancies do not originate in the central nervous system (CNS), the pathologic fracture of the spine would typically be the result of a secondary malignant process. A strong fundamental understanding of how pathologic fractures of the spine may originate is crucial.

"A pathologic fracture simply means that the fracture is caused by some invasive process," says Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York. "Most pathologic fractures of the spine are due to malignancies, but benign neoplasms can result in pathologic fractures as well - in addition to infections of the bone, such as osteomyelitis," Rosenberg explains.

While coders generally want to code the underlying disease as the primary diagnosis, you should abide by the ICD-10-CM guideline's instructions to code the condition being treated as the primary diagnosis:

• "When an encounter is for a pathological fracture due to a neoplasm, and the focus of treatment is the fracture, a code from subcategory M84.5, Pathological fracture in neoplastic disease, should be sequenced first, followed by the code for the neoplasm. If the focus of treatment is the neoplasm with an associated pathological fracture, the neoplasm code should be sequenced first, followed by a code from M84.5 for the pathological fracture."

When you are working in a surgical specialty, making this kind of determination may be easy. However, when a patient reports for imaging, you don't necessarily know what the focus of treatment is. This is partly because the scan is going to help the treating provider make a decision on how to proceed with treatment. In these cases, it's up to the coder to utilize all resources at their disposal - including their own judgement- to decide on which diagnosis to list as the primary.

However, there are rules in place for when the guidelines seem to equally address both the neoplasm and the pathologic fracture. Simply put, in cases where the provider documents neoplasm and the resulting pathologic fracture together, you should code the neoplasm first. There should be no instance in which you would code the pathologic fracture as the primary diagnosis if the underlying neoplasm is a focus of treatment as well. If the indicating diagnoses do not establish an official treatment designation toward one versus the other, you may make the assumption that the referring physician is treating both conditions. In this scenario, you will code the underlying neoplasm first.

Code as Osteoporosis, not Fx, for Osteoporotic-Induced Fxs

Here is a set of guidelines that could understandably be a source of confusion for some coders. Consider an example of a radiologist performing a 72158 (Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar) for an L1 osteoporotic (age-related) fracture.

Now, consider these ICD-10-CM guidelines on coding for osteoporotic fractures:

"A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone."

The guidelines are fairly straightforward, so the correct diagnosis code should be, too. Based on these rules, coders should apply diagnosis code M80.08XA (Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture) and be on their way. However, things become a little more complicated when you check the coding crosswalk for CPT® code 72158. If you check this crosswalk, you will see that diagnosis code M80.08XA is not compatible with 72158. That means that, in all likelihood, it's not a reimbursable diagnosis for this particular procedure. This leaves the coder in a predicament as to what to do next.

1. There are a few different options available at this point. The coder could:
2. Submit the claim as is and appeal the denial using a medical necessity justification,
3. Submit the claim on paper with a written explanation providing medical necessity justification in addition to the ICD-10-CM guidelines referenced above,

Bypass ICD-10-CM guidelines and submit code S32.019A (Unspecified fracture of first lumbar vertebra, initial encounter for closed fracture), which does fall under the coding crosswalk for 22633.

Reviewing each of these options, there aren't many (if any) scenarios in which you should bypass ICD-10-CM guidelines - so you can rule out the third option immediately. The first and second options, on the other hand, are actually both correct. However, the second option is the most practical in terms of optimizing a timely reimbursement. You may also consider reaching out to the payer beforehand to determine the best course of action. Since not all payers are influenced the same way by the ICD-10-CM coding crosswalk, there's always the possibility that the claim gets paid right off the bat.