Orthopedic Coding Alert

"One of the first concepts orthopedic coders learn is the difference between open and closed fractures. However, real-life accidents that cause both a laceration and a fracture dont always cooperate with the distinct fracture definitions as outlined in the CPT and ICD-9-CM manuals.

For example, Carrie Arsenault, ART, CPC, a coding consultant with Health Information Services at Eastern Maine Medical Center, in Bangor, ME, sent chart notes for two tricky coding cases, requesting our comments.

Example 1: Fracture or Repair Treatment?

The patient caught his foot in the bedsheets, striking it on the frame of the bed. The result, according to the operative note, was a significant laceration over the dorsum of the right great toe with the distal phalanx quite floppy. Some bony structure emanated from the side of the laceration. The extensor tendon was completely avulsed from the distal phalanx.

The operative note states that an x-ray revealed a comminuted bilateral fracture of the proximal end of the distal phalanx. On further examination, the physician was able to look into the joint. He removed a couple of bone chips that were pretty much on the surface and not attached to anything. (No anesthesia was used because the patient had no sensation in the foot from a previous surgery.) The laceration was closed using six sutures and the toe was dressed snugly with gauze, incorporating the second toe as a splint.

All sources agree the fracture type in this case should be coded as 826.1 (open fracture of one or more phalanxes of foot). By definition, this fracture type was open, because the outside wound communicates with the fractured bone. The size of the soft- tissue wound is immaterial. The words appears to be bony structure in the operative notes alone indicates this is an open fracture.
However, our sources for this article did not agree on whether the fracture treatment should be coded as open or closed.

Editors Note: Your coding choice will depend on the specifics of your particular fracture case, as well as whether you prefer to take a more conservative approach to coding.

One authority recommended 28505 (open treatment of fracture great toe, phalanx or phalanges, with or without internal or external fixation). She argued that even though the scenario did not match the CPTs definition of open treatmentfor example, the physician did not make an incision and work through that opening to repair the bonethe physician did work through the laceration to remove bone chips. Hence, the treatment was open.

Another expert suggested code 28490 (closed [...]