Get Treatment Types, Diagnoses Straight on Vertebral Fracture Repairs
Do you know the different fracture and treatment types? When your surgeon repairs a patient’s vertebral fractures, several coding questions come immediately to mind. First, you’ll need to know the difference between both open and closed fracture diagnoses and treatments. Once you’ve decided on the type of fracture and treatment, you’ll have to tackle the specific CPT® codes associated with the surgery, as well as any additional services the surgeon may have performed while fixing the fracture. Check out this primer on coding vertebral fracture treatments. Learn How to Identify Open and Closed Vertebral Fractures Coders need to know that open and closed vertebral fracture treatments are different from open and closed vertebral fractures. Closed fractures occur when the vertebral bone breaks without piercing the skin. These are frequently called compression fractures. Closed fractures are often caused by trauma or osteoporosis, and they are primarily treated nonsurgically using pain medications, back bracing, and activity modification — though your surgeon may also choose to operate. An open vertebral fracture occurs when the broken bone breaks through the skin. These are often compound fractures treated by antibiotics as soon as possible to neutralize bacteria. Surgery is all but guaranteed for open fractures, as these are major, traumatic injuries. Remember: An open vertebral fracture does not necessarily equate to open vertebral fracture treatment. Closed treatment is possible on an open vertebral fracture, and vice versa. Always code based on the notes from the practitioner. Be Specific in ICD-10-CM Diagnosis Selection Be aware that for traumatic vertebral fractures, ICD-10-CM does not use a single code for open or closed. Instead, you choose the appropriate code based on spinal region (cervical, thoracic, lumbar, sacral), specific vertebral level, fracture type (wedge compression, burst, unspecified), and encounter type. For example, let’s say the patient suffers from a wedge compression fracture of the first lumbar vertebra. That would direct you to S32.010- (Wedge compression fracture of first lumbar vertebra). Don’t stop there: There are also extensive 7th character options for most vertebral fracture ICD-10-CM codes. Here’s a list of possible options for the 7th character for S32.010-: So, if it’s the initial encounter to deal with the patient’s wedge compression fracture of the first lumbar vertebra, you’d report S32.010A. Look for Conservative Tx Evidence on Closed Treatment Encounters If conservative treatments fail or the pain is severe for a patient with a vertebral fracture, the surgeon may opt for a minimally invasive procedure like a vertebroplasty or kyphoplasty to inject bone cement and stabilize the vertebrae. The surgeon may also opt for closed treatment; for coding purposes. Closed treatment simply means that the surgeon treated the fracture without making any incisions. You’ll report these repairs with one of the following vertebral fracture repair codes: These codes describe the treatment of a vertebral body fracture and are generally reported based on the treatment episode rather than once per vertebra. If the physician provides one course of nonoperative management for multiple fractures, you’ll typically report a single closed treatment code. You would not report one code for each vertebral level unless CPT® guidance allows separate reporting and the documentation supports that distinct treatment. Documentation should include: Incision Marks Open Vertebral Fracture Repairs Open fracture treatment means that the surgeon made an incision (or incisions) when performing the repair. The surgeon typically performs open fracture treatment by stabilizing the bone, holding it in place either internally (with metal plates or screws) or externally (with pins and a stabilizing frame outside of the body). These are the open fracture treatment codes you’ll be using for vertebral fractures; codes are categorized primarily by the approach and then the specific region of the spine being treated: You might also report +61783 (Stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to code for primary procedure)) for guidance during fracture treatment, when appropriate. If the surgeon performs spinal instrumentation or arthrodesis, you’ll generally report those procedures separately. Best bet: If you think you spot a separately codeable service on a vertebral fracture treatment encounter form, be sure CPT® and the individual payer allow you to code it. Remember to Include Stellar Documentation The strongest claims are supported by documentation that clearly demonstrates medical necessity, the exact injury, and the treatment performed. This includes specific injury details like date and mechanism; traumatic versus pathologic fracture; open or closed treatment; and initial, subsequent, or sequela encounter. Documentation of the fracture should include the exact vertebral level, number of vertebrae fractured, fracture type, and whether the fracture is stable/unstable and displaced/nondisplaced (when applicable). Remember to include any imaging findings confirming the fracture. You must also document the treatment rendered with medical necessity describing why the treatment was required. Consider These Clinical Examples Example 1: A 42-year-old patient presents to the emergency department (ED) following a fall from a ladder. The ED physician orders an X-ray demonstrating an acute compression fracture of the L2 vertebral body. The neurosurgeon then performs closed reduction of the second lumbar vertebra. For this encounter, you would report: The initial fitting and application of the brace or cast are bundled into this code, meaning you cannot bill them separately. Example 2: A 24-year-old presents to the ED after a car accident. The ED physician’s CT and MRI of thoracic spine demonstrate an unstable burst fracture of T2. The neurosurgeon then uses stereotactic spinal navigation to successfully clean out the wound and debris, followed by a reduction of the T2 vertebral fracture using a posterior thoracic approach. For this encounter, you would report: Kalie Bothma, CPC, CEDC, CSAF, Medical Coder, Corewell Health
