Don’t Let ICD-10 Orthopaedic Injury Coding Trip You Up

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  • May 1, 2014
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Recognize new coding conventions and brush up on your anatomy for proper coding.

By Heidi Stout, CPC, COSC, CCS-P
Orthopaedic injury coding in ICD-10 is not business as usual. Codes can be up to seven characters long, and are organized by anatomic site rather than by injury type. Codes for post-operative complications are in the body system chapters, and V and E codes are things of the past. What this amounts to is that coders need to know their orthopaedic anatomy when ICD-10 is implemented. To keep from feeling overwhelmed on that fateful day, let’s take a closer look at some of the new ICD-10 coding conventions you may encounter for orthopedic injuries.

Combination Codes

New combination codes for conditions and common symptoms, manifestations, and external causes allow you to report only one ICD-10 code in scenarios where ICD-9-CM requires two codes.
The documentation says, “Wear of articular bearing surface of internal prosthetic right hip joint.” Proper coding is:


There are separate codes for left side, right side, and (in some cases) bilateral, and even codes that are digit specific.
M22.02 Recurrent dislocation of patella, left knee
M16.4 Bilateral post-traumatic osteoarthritis of hip
S64.490- Injury of digital nerve of right index finger (7th character required)

Placeholder “X” and 7th Character

ICD-10 uses a placeholder, which is always the letter X. It has two uses:
5th character: When used as the fifth character for certain six-character codes, the X allows for future expansion without disturbing the sixth-character structure.
M22.3X1 Other derangements of patella, right knee
7th character: When a code has fewer than six characters and a seventh character is required, the X is assigned for all unused characters to meet the requirement of coding to the highest level of specificity.
T84.53XS Infection and inflammatory reaction due to internal right knee prosthesis, sequela
Chapter 19 codes have a seventh character that identifies the episode of care. With the exception of the fracture codes, most categories in chapter 19 have three seventh character values:
A – Initial encounter
An initial encounter character is used while the patient is receiving active treatment for the condition. Some examples of initial encounters are surgery, emergency department encounters, and evaluation and treatment by a new physician.
D – Subsequent encounter
A subsequent encounter character is used for encounters after the patient has received active treatment for the condition, and now is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent treatment are cast change or removal, medication adjustment, and other follow-up visits following treatment for the injury or condition.
S – Sequela
A sequela seventh character is used for complications or conditions that arise as a result (i.e., late effect) of a condition or injury. Examples of sequela are joint contracture after a tendon injury, painful hardware after arthrodesis, and scar formation after a burn.
S51.011A Laceration without foreign body of right elbow, initial encounter
S51.011D Laceration without foreign body of right elbow, subsequent encounter
S51.011S Laceration without foreign body of right elbow, sequela

Complexities of Injury Coding

The demand for specificity in injury coding is tremendous, which places increased demand on the physician to document in detail, and on you to code to a high level of specificity.
S82.221A Displaced transverse fracture of shaft of right tibia, initial encounter for closed fracture
S66.125A Laceration of flexor muscle, fascia and tendon of left ring finger at wrist and hand, initial encounter
T84.220A Displacement of internal fixation device of bones of hand and fingers, initial encounter
ICD-10-CM groups injuries by anatomic site (e.g., shoulder and upper arm) rather than by injury type (e.g., fracture, wound). Injury categories are:

Head (S00-S09)
Neck (S10-S19)
Thorax (S20-S29)
Abdomen, Lower Back, Lumbar Spine, Pelvis, External Genitalia (S30-S39)
Shoulder and Upper Arm (S40-S49)
Elbow and Forearm (S50-S59)
Wrist, Hand, and Fingers (S60-S69)
Hip and Thigh (S70-S79)
Knee and Lower Leg (S80-S89)
Ankle and Foot (S90-S99)
Certain Early Complications of Trauma (T79)
Complications of Surgical and Medical Care, NEC (T80-T88)

The arrangement of codes in each category follows the same pattern for each anatomic site. As an example, look at the codes for injuries to the elbow and forearm:
S50 Superficial injury of elbow and forearm
S51 Open wound of elbow and forearm
S52 Fracture of forearm
S53 Dislocations and sprain of joints and ligaments of elbow
S54 Injury of nerves at forearm level
S55 Injury of blood vessels at forearm level
S56 Injury of muscle, fascia and tendon at forearm level
S57 Crushing injury of elbow and forearm
S58 Traumatic amputation of elbow and forearm
S59 Other and unspecified injuries of elbow and forearm
Within the dislocation category S53, note there are now separate codes for subluxation, in addition to codes for dislocation.
Conduct an in-depth review of the codes for muscle, fascia, and tendon injuries (category S56). There is tremendous specificity within this category; review these codes carefully and arm yourself with anatomical charts and references to assist you in coding these injuries.
S56.193- Other injury of flexor muscle, fascia, and tendon of right middle finger at forearm level (7th character required)
In ICD-9-CM, one code was reported for an open wound with tendon laceration; in ICD-10 separate codes are required for open traumatic wound, and muscle/tendon/fascia laceration or nerve laceration. To locate the code for a tendon injury, look under the main term “injury,” and then “muscle” by site. To locate a code for the wound, look under the main term “laceration,” then look for the specific anatomic site.
The documentation says, “Lacerated flexor tendon of the left ring finger (no foreign body/no damage to nail).” Proper coding is:
For ICD-10, the appropriate seventh character (A, D, S) must be added for episode of care.
Don’t Fumble Fracture Coding
The specificity of the ICD-10-CM fracture codes is daunting. Take great car in making accurate code selections. Displaced vs. non-displaced, open vs. closed, laterality, and type of fracture are some examples of the specificity within the fracture codes. The expanded list of seventh characters not only describes the episode of care, but also whether the doctor is treating an open or closed fracture, nonunion, malunion, or fracture sequela (late effects).
ICD-10-CM guidelines specify a fracture not indicated as open or closed is coded as closed, and a fracture not indicated as displaced or not displaced is coded as displaced. An additional code may be required for an open wound with a fracture or dislocation.
The guidelines state that fractures in patients with known osteoporosis are assigned a code from category M80 Osteoporosis with current pathological fracture, even if there is a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone.
The familiar fracture aftercare codes are gone. For traumatic fracture aftercare, you assign the acute fracture code with the appropriate seventh character. Standard seventh characters for fractures are (there are exceptions to these examples):
A – Initial encounter for 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
Note: There are initial encounter codes for open and closed fractures, but the subsequent encounter codes do not differentiate between the two.
Codes for some fractures in categories S52 Fracture of forearm and S82 Fracture of lower leg, including ankle take specificity a step further. For example, codes S52.21- and S52.22- have a different set of seventh characters. This is a particularly confusing aspect of fracture coding and often requires paging back to locate the correct list of seventh characters.
Special seventh characters for all codes in the S52 and S82 categories (with exceptions) are:
A – Initial encounter for closed fracture
B – Initial encounter for open fracture Type I or II or open fracture NOS
C – Initial encounter for open fracture Type IIIA, IIIB, or IIIC
D – Subsequent encounter for closed fracture with routine healing
E – Subsequent encounter for open fracture Type I or II with routine healing
F – Subsequent encounter for open fracture Type IIIA, IIIB, or IIIC with routine healing
G – Subsequent encounter for closed fracture with delayed healing
H – Subsequent encounter for open fracture Type I or II with delayed healing
J – Subsequent encounter for open fracture, Type IIIA, IIIB, or IIIC with delayed healing
K – Subsequent encounter for closed fracture with nonunion
M – Subsequent encounter for open fracture Type I or II with nonunion
N – Subsequent encounter for open fracture, Type IIIA, IIIB, or IIIC with nonunion
P – Subsequent encounter for closed fracture with malunion
Q – Subsequent encounter for open fracture Type I or II with malunion
R – Subsequent encounter for open fracture, Type IIIA, IIIB, or IIIC with malunion
S – Sequela
Here is the list of options in ICD-10 for coding a fracture of the humerus:

  • 2-part surgical neck
  • 3-part surgical neck
  • 4-part surgical neck
  • Greater tuberosity
  • Lesser tuberosity
  • Greenstick fracture of shaft
  • Transverse fracture of shaft
  • Oblique fracture of shaft
  • Spiral fracture of shaft
  • Comminuted fracture of shaft
  • Segmental fracture of shaft
  • Simple supracondylar w/o intercondylar extension
  • Comminuted supracondylar w/o intercondylar extension
  • Lateral epicondyle
  • Medial epicondyle
  • Incarcerated medial epicondyle
  • Lateral condyle
  • Medial condyle
  • Transcondylar
  • Torus
  • Salter-Harris Type I physeal
  • Salter-Harris Type II physeal
  • Salter-Harris Type III physeal
  • Salter-Harris Type IV physeal

Share this with your physician as an example of why increased specificity in documentation is necessary.
Invest in Proficiency Now
Don’t put off your ICD-10-CM training. The time that you spend becoming ICD-10-CM proficient now will pay huge dividends later. Fail to prepare and the negative impact on your productivity will be significant. Make sure to involve your physicians in the process, too, as they play a huge role in your organization’s successful transition to ICD-10-CM.
Heidi Stout, CPC, COSC, CCS-P, has over 30 years experience in orthopaedic coding. She is the director of the orthopaedic surgery division for The Coding Network, LLC, and has her own consulting business, Coder-On-Call, Inc. Stout has been consulting editor to several medical coding publications and is a member of the AAPC Orthopaedic Steering Committee. She is a member of the Monmouth, N.J., local chapter.

Orthopaedic Surgery COSC

No Responses to “Don’t Let ICD-10 Orthopaedic Injury Coding Trip You Up”

  1. Naveen Allavula says:

    Hi Michelle,
    Thank you for presentation it’s very helpful to me.
    Michelle please clarify my doubt 1.if patient had sprain last month and now patient came with osteoarthritis and also doctor mentioned about that sprain documentation in this visit also for this which condition I’ve to code first Orsteoarthritis or Sprain subsequent.
    Can we code subsequent injury codes secondary?
    I hope you understand my question,please reply to this query.
    Thank you.

  2. Jodi says:

    Is there any more clarification on the use of the “A”,”D”,”S” suffix for injury treatment? For instance, if the patient is seen in the ER for a broken nose and then follows up with their PCP – Would the PCP use “A” initial or “D” subsequent for review of injury and no treatment plans????