Brush Up on A&P When Coding Fractures
Understand anatomy and pathophysiology
By Rhonda Buckholtz, CPC, CPC-I, CPMA, CGSC, CPEDC, COBGC, CENTC
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.
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.
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 the table below, identifies fractures as Type I, II, IIIA, IIIB, IIIC.
|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 seventh 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.
Tina suffered an open fracture of the left radius, type I with dislocation of the radioulnar joint dislocation.
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.
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 seventh 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
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.
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.
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 seventh character extender of “A” for initial encounter. Because the physician did not indicate the fracture as non-displaced or displaced, the guidelines also indicate this encounter would be coded as displaced.
Let’s take this example through the patient’s healing progression.
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.
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 seventh 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.
Rhonda Buckholtz, CPC, CPMA, CPC-I, CENTC, CGSC, COBGC, CPEDC, is vice president of ICD-10 education and training at AAPC.