ED Coding and Reimbursement Alert

Question: What exactly is an open fracture? We are having a debate in the coding office. One coder says an open fracture occurs when the physician has to open up the surgical site to treat the fracture, but I say it's when the bone comes through the patient's skin. Who's right?

Louisiana Subscriber Answer: You are both right. Now it depends on whether you are talking about CPT procedural coding or ICD-9 diagnosis coding.

From an ICD-9 perspective, open fractures occur when a bony fragment sticks through the skin (the fracture may also be called -compound-), or there is an opening between the skin and the fracture. Indications that the fracture was open might include wording such as  -compound,- -missile,- -puncture,- -open- or -with foreign body.-

In a closed fracture, the skin remains intact with no protruding bone at the site. Closed fracture terminology might include terms like -comminuted,- -transverse,- -depressed,- -elevated,- -fissured,- -greenstick,- -impacted,- -linear,-  -march- and -simple.- In addition, most stress fractures are closed fractures.

Tip: Of note, don't confuse an open fracture diagnosis with open treatment. Most ED scenarios do not involve open fracture treatments because they generally require a trip to the operating room. See page 73 of the CPT manual for additional description of open vs. closed treatment.

More help: Here's a list of terms the ED physician might use to describe a patient's fracture:

- Avulsion -- In some instances, the attachment of a tendon or ligament to the bone is strong enough to cause a piece of bone to tear away from the rest the bone, usually in a joint.

- Burst -- A vertebral fracture that is more severe than a compression fracture. In this type of fracture, fragments are forced posteriorly toward the spinal canal.

- Butterfly -- An extra bone fragment seen in comminuted fractures, which is often shaped somewhat like a butterfly.

- Chip -- This refers to a small piece of bone usually near a joint or condyle.

- Comminuted -- A fracture with more than two fracture fragments. Usually this type of fracture is traumatic in nature.

- Complete -- The fracture involves the entire bone cortex.

- Compression -- Seen in vertebral body fractures where the cancellous bone is compressed.

- Depressed -- When a bone that is part of the fracture is pushed down below the level of the skull or joint it is related to, then this is considered depressed.

- Displaced -- In some cases the fractured bone fragments are moved apart from each other, and this is considered displaced.

- Epiphyseal -- A fracture of the epiphysis and physis, or growth plate. 

- Greenstick -- This type of fracture is always found in children and is an incomplete fracture leaving a partial break that is often angulated. 

- Hairline -- These fractures represent a crack in the bone that is not complete.

- Impacted --A fracture in [...]