Wiki Refracture

[daedolos]

How would you code for a refracture? Patient came in for a distal wrist fracture after a fall and two months later fell again and X-rays confirm the same site was refractured.

Peace
?_?

 

[AlanPechacek]

Are you certain this is a "Refracture" and not a "Delayed Union" or "Nonunion" of the original fracture? I would say that in order for it to be a "Refracture" there would have to be existing clinical and radiographic documentation clearly indicating that the original fracture was truly/completely "healed" before the second injury. If that is the case, then I would use an acute fracture S Code for the "new" injury, probably the same as the original unless there are new fracture characteristics that would make it different. If there is no conclusive documentation that the original fracture was truly "healed," then you have a different problem altogether.

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com

 

[daedolos]

Would you then assess the visit as ongoing treatment of the original break and use the "N" designation?

Peace
@_*
Thank you for your insight, sir.

 

[AlanPechacek]

You reference the 7th Character N, which is for Nonunion of an Open Fracture of Gustilo Types IIIA, B, or C (significant trauma and injury). Was the original fracture open or closed? If it was open, then the "relative" risk of a developing a Delayed Union or Nonunion is much higher, particularly at 2 months post injury. If it were a closed fracture originally, and either non-displaced/undisplaced or very minimally or mildly displaced, then there would be a "reasonable" or "possible" chance that it was "healed" by the time of the second injury, depending on a lot of factors related to the patient and their healing capabilities. But, as usual, it all goes back to the Documentation.

Respectfully, Alan Pechacek, M.D.