Revenue Cycle Insider

Use this practical guide to fractures, dislocations, and the associated injuries.

The fractures, dislocations, and injuries that pile onto orthopedic trauma cases can confuse orthopedic coders of all skill levels.

The good news is that even the most complicated trauma cases follow a framework — one on the diagnosis side, one on the procedure side — and both matter equally to a clean claim. Learn the framework, and the chaos starts to look manageable. Let's break it down.

Understand That Fracture Coding Is More Than ‘Broke Bone, Pick Code’

One of the biggest mistakes new coders make when coding fractures is under-specifying. The ICD-10-CM code book is brutally specific, and payers notice when you aren’t.

Every fracture code needs five things nailed down before you move on:

1. Site: You cannot report just “femur.” Is it the neck, shaft, distal end, or the medial condyle? The more specific the documentation is, the more specific your code needs to be. If the note just says, “femur fracture,” that’s a problem that starts with the provider, not you. However, it ends with your query.
2. Laterality: Did the injury occur on the left side or right side, or is it unspecified? Just to be clear: “Unspecified” is not a valid shortcut. It’s a documentation gap, and it’s yours to fix with a query, not to paper over with a vague code.
3. Type: Is the break displaced or nondisplaced? This answer changes treatment decisions and medical necessity. If the note mentions both, ask. Also, remember that ICD-10-CM Official Guidelines, Section I.C.19.c, states “A fracture not indicated whether displaced or not displaced should be coded to displaced.”
4. Open vs. closed: If the fracture is open, you need the Gustilo-Anderson classification (type I, II, IIIA, IIIB, or IIIC). That detail lives in the 7^th character and it affects severity, expected treatment, and what the payer thinks they’re paying for.
5. Encounter type: Also the 7^th character, and this one follows the patient through their entire course of care:

• A = initial encounter (active treatment)
• D = subsequent encounter (routine healing)
• G = subsequent encounter, delayed healing
• K = subsequent encounter, nonunion
• P = subsequent encounter, malunion
• S = sequela

Example: A patient presents for surgical repair of an open oblique displaced fracture of the shaft of the right femur, Gustilo-Anderson type II, initial encounter.

ICD-10-CM code: S72.331B (Displaced oblique fracture of shaft of right femur, initial encounter for open fracture type I or II)

CPT^® code(s): Now cross to the procedure. Was an intramedullary nail used? That’s 27506 (Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary implant, with or without cerclage and/or locking screws). Plate and screws? Assign 27507 (Open treatment of femoral shaft fracture with plate/screws, with or without cerclage). The method matters, so you should confirm the implant and approach in the operative note before you assign the appropriate codes.

Identify the Moving Parts of Dislocations

Dislocations tend to have cleaner documentation than fractures, but they make up for it by almost always bringing company. Associated fractures, ligament tears, and neurovascular injuries tag along frequently, and you should code every one of them separately.

Take the classic anterior shoulder dislocation, closed, initial encounter:

• S43.014A (Anterior dislocation of right humerus, initial encounter)

Now add the concurrent displaced greater tuberosity fracture that shows up in roughly 15 to 35 percent of these cases:

• S42.251A (Displaced fracture of greater tuberosity of right humerus, initial encounter for closed fracture)

In this case, you’ll report both codes. The fracture doesn’t get absorbed into the dislocation code, and the dislocation doesn’t disappear because there’s a fracture. Code both conditions and sequence the codes based on the circumstances of the encounter.

When it comes to the procedure codes, start with the dislocation itself. Assign 23650 (Closed treatment of shoulder dislocation, with manipulation; without anesthesia) for the closed treatment with manipulation but without the use of anesthesia. If the physician physically manipulated the joint to get it back in place and placed the patient under anesthesia, use 23655 (… requiring anesthesia).

Here’s where people get tripped up: If the provider also reduced the tuberosity fracture at the same encounter, that reduction is generally part of the dislocation treatment. You’ll assign 23665 (Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulation) — one event, one CPT^® code. You won’t use a separate code just because two areas were injured.

Where you can bill the fracture treatment separately is when it required its own distinct treatment, such as a separate incision, its own fixation hardware, or something the operative note clearly describes as a separate procedure. If it’s documented that way, bill it and you can back it up. If it’s not, and you report two codes, you could end up in a compliance conversation. If you’re unsure, review your payer’s bundling policy before the claim goes out.

Hip dislocations deserve their own callout. Traumatic hip dislocations frequently occur with acetabular fractures or femoral head injuries. Don’t code a hip dislocation in isolation until you’ve reviewed the full imaging report and operative note. A missing associated acetabular fracture can surface in a recovery audit contractor (RAC) audit, and by then, the chart has long since been closed.

For example, you’ll assign S73.044A (Central dislocation of right hip, initial encounter) to report a central dislocation of the right hip. Code any associated acetabular fractures separately with the S32.4- (Fracture of acetabulum) category.

Don’t Forget to Report any Associated Injuries

This is where revenue leaks quietly. Orthopedic trauma cases almost never present alone. Fractures and dislocations bring friends, and those friends have their own codes and, often, their own procedures.

Ligament and tendon injuries are the most commonly missed conditions on both sides. A knee fracture with an anterior cruciate ligament (ACL) tear receives two diagnosis codes. An ankle fracture with deltoid ligament disruption gets two diagnosis codes. The soft-tissue injury is not included in the fracture code unless the code explicitly says so — and very few do.

Using the ankle fracture and deltoid ligament disruption example, you’d assign the following:

• S82.52XA (Displaced fracture of medial malleolus of left tibia, initial encounter for closed fracture)
• S93.422A (Sprain of deltoid ligament of left ankle, initial encounter)

If the ligament was surgically repaired at the same encounter, that’s its own procedure and it gets its own CPT^® code. The ligament repair doesn’t quietly fold into the fracture fixation code.

Vascular injuries are the conditions that can’t be missed. A distal femur fracture with a popliteal artery injury is a limb-threatening emergency, and the artery injury has ICD-10-CM codes that belong on the claim. Missing it doesn’t just leave revenue behind; it misrepresents the severity of the case and can affect your facility’s case mix index.

Nerve injuries follow the same logic. Brachial plexus injuries from shoulder dislocations, peroneal nerve damage from knee dislocations, and radial nerve injuries in ulnar shaft fractures are all separately reportable. However, the nerve injuries are often skipped.

Example: A patient is diagnosed with a nondisplaced transverse fracture of the left ulna with radial nerve injury.

Assign S52.225A (Nondisplaced transverse fracture of shaft of left ulna, initial encounter for closed fracture) and S54.22XA (Injury of radial nerve at forearm level, left arm, initial encounter).

The CPT^® coding of nerve injuries is where people either upcode or downcode their claims. A quick way to think about it is if the surgeon moved the nerve aside to get to the fracture site, that’s part of the approach. It’s incidental and not billable on its own. But if the nerve was actually repaired (sutured, grafted) or the surgeon performed neurolysis as its own distinct procedure, that’s separately billable and it belongs on the claim. The operative note will tell you which one happened. If the report doesn’t clearly say if a procedure was separate and distinct, that’s your query right there.

Remember the Details That Will Save Your Claim

Here are a few things to keep in mind that sound obvious — until you’re moving quickly through a high-volume queue:

• Sequence by the reason for the encounter: Definitive fracture repair? The fracture leads. Presenting for hardware failure or post-op infection? The complication leads, and the original fracture code follows.
• The 7^th character follows the patient, not the calendar: A patient presenting months later for nonunion is still coded with “K.” That’s not a workaround, that’s the system working exactly as intended. Healing status drives the character, not the time elapsed.
• Pathological fracture vs. traumatic fracture is non-negotiable: A patient with metastatic cancer who fractures a vertebra reaching for a coffee cup is not coded the same as a construction worker who falls from a scaffold. Both may end up in the same operating room (OR) getting the same procedure, but the coding looks nothing alike. Pathological fractures due to metastatic disease codes live in the M84.5- (Pathological fracture in neoplastic disease) subcategory. Traumatic fractures are S codes. Mix them up and you’ve told the payer a completely different clinical story, which can create problems that are much harder to fix after the fact than before.
• Laterality defaults: Every coder has been tempted to use an unspecified code when the note is vague, but you should resist the temptation every time. Unspecified codes trigger edits, flag claims for review, and signal to auditors that documentation standards are loose. Query the provider. A quick addendum costs nothing compared to a recoupment or denial from the payer.

ICD-10-CM tells the patient’s story. CPT^® tells the story of what was done about it. Miss details on either side and the whole claim limps. Read the operative note like you’re the one holding the retractor. The anatomical site, the technique, and the associated injuries that got addressed while the surgeon was already in there are all documented if you look for them. The difference between a clean claim and a denial is almost always something somebody skipped.

The cases are complex, but the approach doesn’t have to be.

Valerie Ramirez, CPC, CPMA, CRC, COSC, Coding Integrity Specialist,
United Musculoskeletal Partners