Radiology Coding Alert

Question: A patient was treated for a fracture of the second metatarsal. Four weeks later, an X-ray revealed that the fracture had failed to heal at all. How should I code for the condition?

California Subscriber

Answer: The two encounters have different coding requirements. For the first visit with initial diagnosis of the fracture, use 825.25 (Fracture of other tarsal and metatarsal bones, closed; metatarsal bone[s]).

For the second visit, the diagnosis would be 733.82 (Nonunion of fracture) with late-effect code 905.4 (Late effect of fracture of lower extremities) as a secondary diagnosis.

ICD-10: Under ICD-10, you’ll choose your codes from the range S92.32-- (Fracture of second metatarsal bone …). You’ll choose the final two digits based on a variety of factors, including the foot involved, displaced, nondisplaced, open, closed, the encounter, routine or delayed healing, nonunion, or malunion. For instance, compare the definitions of S92.324A (Nondisplaced fracture of second metatarsal bone, right foot; initial encounter for closed fracture) and S92.324K (Nondisplaced fracture of second metatarsal bone, right foot; subsequent encounter for fracture with nonunion).