Orthopedic Coding Alert

Question: The orthopedist just treated a patient who was diagnosed with a displaced bimalleolar fracture of the right lower leg. This is an initial encounter, and the provider documents that the fracture is type IIA. What is the correct diagnosis code for this injury?

Hawaii Subscriber

Answer: You should report S82.841A (Displaced bimalleolar fracture of right lower leg, initial encounter for closed fracture) in this case. That’s a long ICD-10 code with a lot of moving parts, especially the seventh character.

Take a look at this seventh character list of ankle fracture code options. These are the open fracture designations, which are based on the Gustilo open fracture classification:

• B (Initial encounter for open fracture type I or II)
• C (Initial encounter for open fracture type IIIA, IIIB, or IIIC)
• E (Subsequent encounter for open fracture type I or II with routine healing)
• F (Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing)
• H (Subsequent encounter for open fracture type I or II with delayed healing)
• J (Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing)
• M (Subsequent encounter for open fracture type I or II with nonunion)
• N (Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion)
• Q (Subsequent encounter for open fracture type I or II with malunion)
• R (Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion)

Also, for closed fractures, you have the following seventh character choices:

• A (Initial encounter for closed fracture)
• D (Subsequent encounter for closed fracture with routine healing)
• G (Subsequent encounter for closed fracture with delayed healing)
• K (Subsequent encounter for closed fracture with nonunion)
• P (Subsequent encounter for closed fracture with malunion)

Finally, for sequela, you would use S (Sequela).