Radiology Coding Alert

Question: A 52-year-old patient arrived at our emergency department (ED) with severe left leg pain. The patient explained they experienced a hard fall while skateboarding. A radiologist captured three views of the patient’s left upper leg and diagnosed the patient with a closed, displaced oblique fracture of the left femur shaft. The patient then underwent an open surgery to set the bones, and the surgeon used uniplane external fixation to aid in the healing process.

What codes should we use to code this encounter?

California Subscriber

Answer: Two CPT^® and two ICD-10-CM codes represent this encounter. The radiologist should assign 73552 (Radiologic examination, femur; minimum 2 views) to report the X-rays of the patient’s leg, and the surgeon should assign 27507 (Open treatment of femoral shaft fracture with plate/screws, with or without cerclage) to report the open treatment and external fixation.

To report the femur fracture diagnosis, you’ll assign S72.332A (Displaced oblique fracture of shaft of left femur, initial encounter for closed fracture). Since the patient presented to the ED for care, choosing the diagnosis code with 7th character A is appropriate to report the initial encounter.

The patient also suffered the injury while skateboarding, so you may assign Y93.51 (Activity, roller skating (inline) and skateboarding). According to the ICD-10-CM Official Guidelines, Section I.C.19.c, “Assign a code from category Y93, Activity code, to describe the activity of the patient at the time the injury or other health condition occurred.” The code is used only once, “at the initial encounter for treatment.” Activity codes aren’t required, but are informational, which allows you to paint the picture of the encounter.