Anesthesia Coding Alert

Coding for an anesthesiologist's involvement in bone fracture repair requires knowing whether the procedure is a reduction or repair and the type of treatment closed, open or percutaneous skeletal fixation. However, the patient's chart doesn't always supply that information, so coders must understand key phrases and work closely with the anesthesia provider to supply adequate documentation.
Reduction or Repair, Open or Closed
Reductions are the alignment of fractured bone segments in an acceptable manner; once aligned, the fragments must be fixed in place so the bones don't get out of alignment and need to be reduced again. The terms "reduction" and "repair" are sometimes almost used interchangeably, but repairs are not usually associated with fractures, says Sharon Ryan, senior coder with the physician group Anesthesia Associates of Massachusetts in Westwood.
 
CPT 2002 states, "Closed treatment specifically means that the fracture site is not surgically opened (exposed to the external environment and directly visualized) Open treatment is used when the fracture is surgically opened (exposed to the external environment). In this instance, the fracture (bone ends) is visualized and internal fixation may be used Percutaneous skeletal fixation describes fracture treatment which is neither open nor closed. In this procedure, the fracture fragments are not visualized, but fixation (i.e., pins) is placed across the fracture site, usually under x-ray imaging."
 
"Open or closed tells whether or not an incision is made in the skin and muscle over the fracture site," explains Mike Casto, assistant director of Anesthesia Associates in Alexandria, Va. "When a diagnosis is 'open fracture' that means the bone has broken through the skin. For a closed reduction, the physician puts the bone back in place without opening the patient up.
 
"Whether the fracture is open or closed is generally easy to see," Casto continues. "When there is an open fracture, there is an open wound of the skin at the site of the fracture with a portion of the bone protruding. Closed fractures don't break the skin. If an incision is made when gaining access to the fracture site, the procedure would be an open reduction; when pins are placed through the skin the reduction is percutaneous."
 
Ryan adds that when the operative notes specify open or closed with a fracture, the physician is usually referring to a reduction, not a repair.

Types of Reductions
Examples of types of reductions that fall into each category are:
Open reduction: One example of an open reduction is a fracture of the femoral neck in which an incision in the hip region is required to gain access to the upper femur. A plate and screw-type internal fixation device could then be implanted to stabilize the sections of bone.
Closed reduction: This type of repair [...]