Put the Pieces Back Together to Accurately Code Skull Fractures, Repairs
It’s the small details that make or break an accurate diagnosis. Patients who suffer from skull fractures present challenges for coders when choosing diagnosis codes and procedure codes. Why? Both choices depend on several factors that you’ll have to find in the notes; failing that, you’ll need to query the surgeon to make sure you get each skull fracture repair and diagnosis code correct. Read on for more information on choosing the correct ICD-10-CM codes for skull fractures, and the correct CPT® codes for fracture repairs. Look to Several Elements for ICD-10-CM Choice When choosing an appropriate skull fracture diagnosis code, you need to focus on the anatomic location, encounter type (initial, subsequent, sequela), and whether it was an open or closed fracture. Be sure to scan the indication to see if the preoperative and postoperative reports are lacking this information. A query to the provider is recommended if these are missing from the entirety of the operative note. In addition to a skull fracture ICD-10-CM code, you’ll need to code any hematoma, laceration, edema, or concussion the patient may have suffered. Typically, skull fractures are traumatic — so be sure to add your external cause code specifying how the patient obtained the injury. External cause and location of incident are helpful to capture the entire incident. Use These ICD-10 Codes for Traumatic Skull Fractures When a patient suffers a traumatic skull fracture, these are some of the codes you’ll most likely choose from for a diagnosis. The exact code will vary depending on whether the fracture was open or closed, as well as encounter type. Select Repair Procedure Code Step-by-Step A skull fracture repair will be performed by open or closed treatment. If the surgeon performs the repair using closed treatment, you will simply report the appropriate evaluation and management (E/M) code for the visit. Some of these might be office/outpatient E/Ms, but be mindful of the E/M setting on closed skull fracture repair. Some of the encounters can take place at a facility, in which case you’ll use different E/M codes. When the surgeon performs open treatment, coders could be tipped off if encounter notes indicate that the surgeon performed elevation or depression of the fracture. Other clues indicating open treatment include notes indicating: Open skull fracture repairs can include a microscope for assistance, which you’d report with +69990 (Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure)). The surgeon might also use stealth intradural neuro-navigation, which you’d report with +61781 (Stereotactic computer-assisted (navigational) procedure; cranial, intradural (List separately in addition to code for primary procedure)); or extradural neuro-navigation, which you’d report with +61782 (… cranial, extradural (List separately in addition to code for primary procedure)). Consider This Clinical Example A 4-year-old patient is brought into the emergency department (ED) after being a passenger in a car accident with a truck. The patient lost consciousness for five minutes. The surgeon orders imaging, which shows the patient has an open depressed frontal skull fracture with a subdural hematoma. After a high level of medical decision making (MDM), the neurosurgery team decides to take the patient into emergent surgery to elevate the comminuted, depressed fracture fragments. A microscope is brought into the field to elevate the fracture. The surgeon removes fragments in the dura and repairs minor tears, then closes the area without issue. For this encounter, you’d report: Kalie Bothma, CPC, CEDC, CSAF, Medical Coder, Corewell Health
