Radiology Coding Alert

Question: A patient presented to an outpatient radiology practice after suffering a fall at home. The patient fell down their deck stairs and hurt their right wrist. The patient’s primary care physician (PCP) referred the patient to the radiology practice for X-rays to evaluate for a fracture. The radiologist captured postero­anterior (PA) and lateral views of the wrist. After reviewing the images, the radiologist issued their findings of a right displaced distal pole of scaphoid fracture.

What codes would I use to report this encounter?

Colorado Subscriber

Answer: Let’s start with the imaging procedure. You’ll assign 73100 (Radiologic examination, wrist; 2 views) to report the two-view wrist X-rays, which includes the PA and lateral views. Depending on your payer’s preferences, you might also need to append modifier RT (Right side) to indicate which wrist the radiologist imaged.

Next, you’ll assign S62.011A (Displaced fracture of distal pole of navicular [scaphoid] bone of right wrist, initial encounter for closed fracture) to report the radiologist’s findings. Look for Fracture, traumatic > carpal bone(s) > navicular > distal pole (displaced) in the ICD-10-CM Alphabetic Index. When you verify the code in the Tabular List, you’ll find 6th and 7th characters are required to complete the diagnosis code.

In this case, the 6th character specifies the laterality, and the 7th character indicates the encounter type and whether the fracture is open or closed. You didn’t indicate if the fracture was open or closed, but the ICD-10-CM Official Guidelines, section I.C.19.c, state “[a] fracture not indicated as open or closed should be coded to closed.” Using “A” as the 7th character is, therefore, correct in this case since the patient is seeking active treatment for the fracture and there isn’t documentation listing the fracture as open or closed.