Radiology Coding Alert

Question: How should I code the following abbreviated report?

Header: XR wrist AP + Lat

Right wrist x-ray (3) views

Florida Subscriber

Answer: You should report 813.41 (Fracture of radius and ulna; lower end, closed; Colles' fracture) for the diagnosis.

Term tip: ICD-9 defines a Colles' fracture as a "break of lower end of radius; associated with backward movement of the radius lower section."

Closed fracture clue: The sample documentation doesn't state "open" or "closed" fracture specifically. But ICD-9's "fracture" index entry states that "impacted" indicates a closed fracture, with or without healing, unless the documentation specifies the fracture is open or compound.

In a closed fracture, the skin remains intact, with no protruding bone at the site. "Impacted" means a bone's one broken end is wedged into the other broken end.

CPT: You should report 73110 (Radiologic examination, wrist; complete, minimum of three views) for the three-view wrist x-ray. The header specifies AP (anteroposterior) and lateral views, but you shouldn't base your code on the header. Fortunately, the radiologist documents three views within the report.