Fine Details Are Critical in Fracture Coding
By Ken Camilleis, CPC, CPC-I, CMRS, CCS-P
Analyze documentation to understand the intricacies of diagnostic and procedural fracture coding.
Because there are so many types of fractures and fracture treatments, appropriate diagnostic and procedural coding is very complex. Obtaining appropriate reimbursement in compliance with payer regulations and coding guidelines requires a thorough analysis of the documentation. Before you can do that, however, you have to understand what you’re looking at, and know which details you’re looking for.
Code by Location/Open or Closed
The formal definition of fracture in ICD-9-CM is, “a complete or incomplete break in a bone resulting from application of excessive force.” The ICD-9-CM Alphabetic Index (Volume 2) arranges fracture diagnosis codes alphabetically by location, and often by relative position of a given site (e.g., distal end or proximal end). For example, the entry “fracture; clavicle” contains codes specific to the interligamentous region, the acromial end, the shaft (middle third), and the sternal end of the bone.
The first three digits of a fracture diagnosis code identify the general location of the fracture (e.g., 800.xx-804.xx for skull fractures, 805.xx-809.xx for neck and trunk fractures, etc.). The fourth digit generally identifies the fracture as either open or closed. Open means there is a skin wound caused by the fracture. Closed means there is a breakage of bone but not of surrounding skin. If a fracture is not specified as either open or closed, you must assume it is closed, as indicated by an instructional note at the beginning of ICD-9-CM chapter 17, in the Fractures section (categories 800-829).
Most ICD-9-CM fracture diagnoses require a fifth digit. Typically, the fifth digit of a fracture repair diagnosis code indicates more specific bones within the general site, but may also indicate other specified information. For example, when coding for skull fracture (800.xx-804.xx), the fifth digit indicates if there was a loss of consciousness, how long it lasted, and whether there was a return to the previous level of consciousness. Clinicians should be careful to document these and other associated conditions (e.g., spinal cord injury).
Stress Fractures May Warrant Causation Codes
Clinicians and coders must often distinguish between traumatic fractures (caused by an acute injury), pathologic fractures (caused by an evolving disease process that weakens bone, such as osteoporosis), and stress fractures (due to repeated strain from overuse).
Traumatic fractures are reported from ICD-9-CM categories 800-829 while the patient is receiving active treatment, such as surgical or emergency department care. Aftercare treatment requires different codes (see “Fracture Aftercare Calls for Unique Coding” on page 42 for more detail).
To identify a pathologic fracture receiving active treatment, report 733.1x.
For example, a 58-year-old man is diagnosed with a pathologic fracture of his C6 spinous process. Because this is a pathologic fracture, the correct code is 733.13 Pathologic fracture of vertebrae.
If the same patient had suffered from a traumatic fracture, you would code from category 800-829. For the C6 spinous process, you would report 805.06 Fracture of vertebral column without mention of spinal cord injury; cervical, closed; sixth cervical vertebra.
A stress fracture, aka an insufficiency fracture, is caused by repeated strain from overexertion or due to a weakened bone (i.e., osteoporosis). Look to category 733.93-733.99 to report stress fractures. Also assign the appropriate diagnosis code to describe any underlying external cause.
For example: A 13-year-old boy was lifting heavy weights at his school’s gym when he began to clutch his left knee in pain. He was diagnosed with a stress fracture of his tibia shaft. Because this is a stress fracture rather than an impact fracture, and is specified as of the tibia, the proper code is 733.93 Stress fracture of the tibia or fibula. You must also specify the external cause of the stress fracture, including E927.0 Overexertion from sudden strenuous movement and E010.2 Activity involving other muscle strengthening exercises; free weights. You can also specify place of occurrence, E849.6 Place of occurrence; public building.
History of pathologic fracture or stress fracture, when documented, should be reported secondarily to the active fracture. The history codes are V13.51 Personal history of pathologic fracture and V13.52 Personal history of stress fracture.
Tips for Diagnosis Sequencing
ICD-9-CM Official Guidelines for Coding and Reporting (section I.C.17.b) stipulates three primary rules for assigning and sequencing fracture diagnoses:
- Code all fractures separately. This includes multiple unilateral or bilateral fractures classified to different fourth-digit subdivisions (bone part) within the same three-digit category (bone).
- Combination codes are used only for triage on patients with multiple injuries when the extent of the individual injuries is unknown prior to transfer of care.
- Report multiple fractures by severity (most severe first), as determined by the treating physician.
For example, following a motor vehicle accident, the patient arrives in the emergency department with multiple open depressed skull and facial bone fractures, facial lacerations, and contusions. She has experienced a 90-minute loss of consciousness. The appropriate ICD-9-CM code is 804.63 Multiple fractures involving skull or face with other bones; open with cerebral laceration and contusion; with moderate [1-24 hours] loss of consciousness. In this case, a combination code may be used. The code also describes other, associated conditions (e.g., loss of consciousness).
CPT® Coding for Fracture Treatment
“Fracture” appears in the CPT® Index as a main term (just as it does in ICD-9-CM). This is where you’ll begin your search for fracture treatment codes. The terms “fracture” and/or “dislocation” appear at the category level in the main section of the CPT® codebook. For example, codes 27750-27848 represent treatments of fractures of the tibia, fibula, and ankle joints.
There are three major approaches to treat fractures: closed, open, and percutaneous.
- Closed treatment means the fractured bone is not exposed to the view of the surgeon.
- Open treatment means the bone is exposed by incision.
- Percutaneous treatment (aka percutaneous skeletal fixation) involves the placement of a fixative device—such as a rod, wire, or pin—across the fractured bone usually under imaging guidance.
The treatment type will not necessarily match the fracture type. For instance, an orthopedic surgeon may perform an open treatment of a closed fracture, or a percutaneous treatment of either a closed or open fracture.
When coding for physician services for surgeries to correct fractures, pay particular attention to terms such as closed/open/percutaneous treatment and details describing the specific site (such as nasal bone, nasal septum, nasoethmoid, nasoethmoid complex, or nasomaxillary). You’ll also need to understand which combinations of terms are mutually exclusive with each of the three treatment methods. Read all CPT® descriptors carefully, noting terms such as “open reduction with internal fixation.” Observe when certain services (such as the application of the fixative device) are included in the descriptor, and not reported separately.
For both procedural and diagnostic coding, experts generally agree that if one bone is both fractured and dislocated, code only the service and diagnosis for the fracture and not the dislocation (see Coding Clinic, third quarter 1990, page 13). Some CPT® codes specifically describe surgeries on a bone that is both fractured and dislocated.
For example, an 87-year-old man with history of falling presents for repair of fractured proximal ulna and dislocated radial head. He slipped on ice, landing on his right elbow, and sustained a Monteggia fracture. The orthopedic surgeon performed an open reduction and internal fixation (ORIF) over the site.
The correct CPT® and ICD-9-CM codes to describe this scenario are:
- 24635-RT Open treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), includes internal fixation, when performed-Right side to describe the ORIF for Monteggia fracture.
- 813.03 Fracture of radius and ulna; upper end, closed; Monteggia’s fracture for the traumatic fracture. Because the fracture is not indicated as open, you would code it as closed.
- V15.88 History of fall indicates the patient has a history of falling.
- E885.9 Fall from other slipping, tripping, or stumbling describes a fall on same level, such as slipping.
- E849.0 Place of occurrence, home notes where the fracture occurred.
You would not code the dislocation because the same bone is also fractured.
In a second example, a 26-year-old woman is injured in a downhill skiing accident. She fractures and dislocates her left shoulder. The impact was to her left distal humerus, medial condyle. Using anesthesia, the orthopedic surgeon repairs her shoulder by reducing the fracture without directly visualizing the injured site.
The correct CPT® and ICD-9-CM codes are:
- 23665-LT Closed treatment of shoulder dislocation with fracture of greater humeral tuberosity, with manipulation; requiring anesthesia-Left side. Because the orthopedist performed the surgery without visualizing the fracture site, this is a closed treatment.
- 812.43 Fracture of humerus; lower end, closed; medial condyle. Do not code the dislocation as well because the fracture of the same bone is the more serious injury.
- E885.3 Fall from skis
- E003.2 Activities involving ice and snow; snow (alpine) (downhill) skiing, snow boarding, sledding, tobogganing and snow tubing
This is a lot of information to take in. In a nutshell, just remember: Diagnosis coding should report the location of the fracture, the severity of the fracture, and whether there were complications due to the fracture. Procedure coding should report the approach for treatment, the location being treated, and any extenuating circumstances due to treatment.
Fracture Aftercare Calls for Unique Coding
Codes 800-829 for traumatic fractures, 733.1x for pathologic fractures, and 733.93-733.99 for stress fractures should be reserved for when the patient is receiving active treatment for the fracture. ICD-9-CM Official Guidelines for Coding and Reporting defines active treatment as “surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.”
When reporting services provided during the healing or recovery phase of the fracture, turn instead to fracture aftercare codes from category V54. Examples of aftercare include cast change or removal, removal of external or internal fixation devices, medication adjustment, and follow-up fracture treatment visits.
ICD-10-CM Ups the Documentation Ante
As ICD-9-CM gives way to ICD-10-CM on Oct. 1, 2014, the importance of complete documentation for fracture coding will take a big leap forward. To cite two examples: In ICD-9-CM, there is no provision for specifying laterality (left or right) and healing processes are very broadly classified. For example, there is only one code for a malunion of a fracture (733.81) and only one code for a nonunion (733.82).
In ICD-10-CM, not only do we indicate laterality but we also have the capability to code a disease process known as “stage of healing.” The four distinct fracture healing processes are:
- Routine healing
- Delayed healing
These features, as well as routine and delayed healing, are built into the seventh-character “extension” of the ICD-10-CM code. Aftercare following fracture treatment is indicated by the extension “D,” and late effects of fractures are indicated by the extension “S.” In ICD-10-CM, closed and open fractures are further broken down into many subdivisions, which are only tabulated in a list in ICD-9-CM.
When mapping fracture codes from ICD-9-CM to ICD-10, it becomes clear that much more information must be documented in medical records and operative reports. For example, a patient suffers a traumatic open fracture to the lower end of the femoral condyle. In ICD-9-CM, this is simply coded as 821.31 Fracture of other and unspecified parts of femur; lower end, open; condyle, femoral. In ICD-10-CM, however, we add the dimensions of:
- Which condyle (unspecified, lateral or medial; fifth character)
- Laterality (right or left thigh or unspecified; sixth character)
- Whether displaced or nondisplaced (also in the sixth character)
- Type of open fracture (using the Gustilo Open Fracture Classification System; seventh character extension)
- Stage of healing (as listed above; also in the seventh character)
A single ICD-9-CM code (821.31) potentially crosswalks to 36 possible ICD-10-CM code choices in the category S72.4- (including three designations of condyle, three designations of laterality, two binary designations of displacement, and two designations of Gustilo groups [Type I/II and Type IIIA/IIIB/IIIC]). The S72.42- and S72.43- subseries follow a similar progression, with the fifth character representing the lateral condyle in S72.42- and the medial condyle in S72.43-. All of these codes map backward from the general equivalence mapping (GEM) files to 821.31.