ICD-10: Brush Up on A&P When Coding Fractures

Developing a better understanding of anatomy and pathophysiology (A&P) is one challenge you will face with ICD-10 implementation. The good news is brushing up on A&P, while seeing how it’s applied in the ICD-10-CM Official Guidelines for Coding and Reporting, will make ICD-10 code assignment easier. As an example, let’s look at fracture coding.

Locate Fractures

Traumatic fracture codes are found in chapter 19 of ICD-10-CM, “Injury, Poisoning and Certain Other Consequences of External Causes (S00-T98).” This chapter uses the S-section for coding different injuries related to single body regions, and the T-section to cover injuries to unspecified body regions, as well as codes for poisoning and certain other consequences of external causes.

Define Fractures

A bone fracture is a medical condition in which there is a break in the continuity of the bone. A bone fracture can be the result of high-force impact or stress, or trivial injury as a result of a medical condition that weaken the bones (e.g., osteoporosis, bone cancer, or osteogenesis imperfecta). The latter type of fracture is a pathologic fracture.
Codes for open fractures (where bone pierces the skin) contain a much higher level of specificity in ICD-10-CM, and further classification is needed for open fractures using the Gustilo open fracture classification system. This system, shown in Table A, identifies fractures as Type I, II, IIIA, IIIB, IIIC.

Gustilo Classification
I Low energy, wound less than 1 cm
II Wound greater than 1 cm with moderate soft tissue damage
 III High energy wound greater than 1 cm with extensive soft tissue damage
IIIA Adequate soft tissue cover
IIIB Inadequate soft tissue cover
IIIC Associated with arterial injury

You must have an in-depth knowledge of fracture classification systems to assign fracture codes appropriately. For example, ICD-10-CM guidelines state, “A fracture not indicated as open or closed should be coded to closed. A fracture not indicated whether displaced or not displaced should be coded to displaced.”
Fractures also require the use of a 7th character extender. The ICD-10-CM guidelines indicate:
Initial vs. Subsequent Encounter for Fractures
Traumatic fractures are coded using the appropriate 7th character extension for initial encounter (A, B, C) while the patient is receiving active treatment for the fracture. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician. The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.
Fractures are coded using the appropriate 7th character extension for subsequent care for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase. Examples of fracture aftercare are: cast change or removal, removal of external or internal fixation device, medication adjustment, and follow-up visits following fracture treatment.
Care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes.
Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7th character extensions for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R).
The aftercare Z codes should not be used for aftercare for traumatic fractures. For aftercare of a traumatic fracture, assign the acute fracture code with the appropriate 7th character.
Example: Tina suffered an open fracture of the left radius, type I with dislocation of the radioulnar joint dislocation.
ICD-10-CM coding: S52.372B Galeazzi’s fracture of the left radius, initial encounter for open fracture type 1
The Galeazzi fracture is a fracture of the radius with dislocation of the distal radioulnar joint. It classically involves an isolated fracture of the junction of the distal third and middle third of the radius with associated subluxation or dislocation of the distal radioulnar joint; the injury disrupts the forearm axis joint.

Increase Specificity

The clavicle, or collarbone, is a long bone of short length that serves as a strut between the scapula and the sternum. It is the only long bone in body that lies horizontally. It makes up part of the shoulder and the pectoral girdle, and is palpable in all people. In people who have less fat in this region, the location of the bone is clearly visible where it creates a bulge in the skin.
Even though there is only one long bone for the clavicle, there are 24 coding choices in ICD-10-CM. These choices consist of four subcategories:
S42.0       Fracture of clavicle
S42.01     Fracture of sternal end of clavicle
S42.02     Fracture of shaft of clavicle
S42.03     Fracture of lateral end of clavicle
In each subcategory there are choices for displaced and non-displaced, as well as laterality. A requirement for coding a clavicle fracture is the 7th character extension. Choices for this subcategory consist of:
A             Initial encounter of closed fracture
B             Initial encounter for open fracture
D             Subsequent encounter for fracture with routine healing
G             Subsequent encounter for fracture with delayed healing
K             Subsequent encounter for fracture with nonunion
P             Subsequent encounter for fracture with malunion
S              Sequela
According to the American Academy of Family Physicians (AAFP), the anatomic site of the clavicle fracture is typically described using the Allman classification, which divides the clavicle into thirds. Group I (midshaft) fractures occur on the middle third of the clavicle; group II fractures on the lateral (distal) third; and group III fractures on the medial (proximal) third. Knowing these terms and classification can help in code assignment.
Example: Tim was seen in our office for pain with movement of his upper right arm and shoulder region. This pain has been present for about six weeks. He first noticed it after he was playing football at his family reunion three weeks ago, and has been treating himself with ibuprofen with no relief. In-office X-rays indicate a group II fracture of the right clavicle.
ICD-10-CM coding: S42.031A Displaced fracture of lateral end of right clavical, initial encounter
Review of the guidelines indicate that because this is the first time the patient is being seen for this condition, we would assign the 7th character extender of “A” for initial encounter. And since the physician did not indicate the fracture as non-displaced or displaced, the guidelines also indicate this encounter would be coded as displaced.
If we take this example through the patient’s healing progression, we have the following example:
Example: Tim returned to our office three months later with complaints of intermittent pain of the right upper extremity. The physician determined it was a result of his previous fracture and took in-office X-rays that indicated a nonunion.
ICD-10-CM coding: S42.031K Displaced fracture of the lateral end of the right clavicle, subsequent encounter for fracture with nonunion
Six months later, Tim returned for aftercare follow-up from his now-healed fracture. In ICD-10-CM, we code the aftercare with the same acute fracture code, with the 7th character extender for sequela. The coding would now look like:
S42.031S Displaced fracture of the lateral end of the right clavicle, sequela
With working knowledge of anatomy and pathophysiology, you can appropriately assign codes in ICD-10. Refreshing your current skill set will be necessary so productivity will not suffer with ICD-10 implementation.
ICD-10-CM Official Guidelines for Coding and Reporting 2011AAPC’s Anatomy and Physiology for ICD-10-CM
Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC, is vice president of ICD-10 education and training at AAPC.

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No Responses to “ICD-10: Brush Up on A&P When Coding Fractures”

  1. Needhu says:

    That was really helpful

  2. Erika says:

    Thank you for this article! I have a question: The case I’m coding is for treatment of closed fracture of femoral shaft (S72.301A), but the provider also noted that the patient has another fracture (not being treated in this visit) C-7 transverse process fracture. Do I have to code the C-7 transverse process fracture if is not being treated at this encounter?

  3. Jean Cantieni says:

    Will there me new 2017 codes for ‘atypical fractures?’

  4. Letha Friedman says:

    I found this very helpful, however, I have a surgical intervention for facial fractures that occurred more than a year s/p fractures. The patient did not delay seeking surgical care. The care provided remained conservative: ice, medications and referrals to specialists for x-rays that revealed a broken nose. The initial CT was obtained 2 months after his injury and was read as healed fractures. The patient continued to be symptomatic: headaches, blurred vision and an inability to breathe out of the left nostril. He changed his ENT specialist who repeated the facial CT (14 months after the initial injury) revealing chronic fractures and non-union. His only surgical intervention to repair the nasal and facial fractures was 15 months after his initial injury and conservative care. My question is, should the hospital dx code be as an initial encounter, subsequent encounter, non-healing or non-union encounter? S022XXA – Fracture orbital floor, initial encounter OR S022XXG OR S022XXK
    Thank you in advance for your assistance.