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Radiology Coding Alert

READER QUESTIONS:

Assume Closed Fracture When Details Are Absent

Published on Fri Nov 25, 2005

Question: If our radiologist doesn't specify whether a fracture is open or closed, how should we code for it?


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Answer: When you don't have the details, code for a closed fracture.

Example: Your radiologist performs an x-ray and reports multiple fractures of the hand bones.

What to do: Because the radiologist doesn't specify whether the fractures are open or closed, report 817.0 (Multiple fractures of hand bones; closed).

Definitions: An open fracture involves an open wound involved with the fracture. If the patient has a simple laceration that doesn't communicate with the fracture, don't consider this to be open. Terms related to open include compound, infected, missile, puncture, and with foreign body.

A closed fracture, on the other hand, is one that doesn't break the skin. You may see the following terms with closed fractures: comminuted, depressed, elevated, fissured, greenstick, impacted, linear, simple, slipped epiphysis, and spiral.
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