Wiki Orthopedic Diagnosis coding for Compression Fractures

[tldixon@mokancomm.net]

We need some guidance, and we also need to know how the choice of codes affects reimbursement.

It is very difficult on our older patients with vertebral compression fractures to decide whether they have pathological fractures due to osteoporosis or traumatic fractures. In many cases, the underlying diagnosis of osteoporosis, steroid-induced osteoporosis, etc., won't be definitively established until after later work-up. For purposes of the trauma program, we do not consider falls from standing height in older individuals to be traumatic fractures. But insurance companies may view it differently. One case in point is the patient we currently have in the hospital. She had an L1 compression fracture due to a fall against a sink from standing height, having been jumped on by a dog, and she has previously diagnosed alleged osteoporosis (studies done elsewhere years ago, so we don't have the studies.) Is this a pathological fracture due to osteoporosis or a traumatic fracture? For purposes of our trauma program, a patient like this wouldn't get in the registry because it would not be considered a traumatic fracture. Also, what are the reimbursement ramifications? If a patient like this needs a kyphoplasty to retard progression of deformity and control pain, do insurance companies and Medicare cover the procedure for both pathological AND traumatic fractures or not????
I would appreciate any and all feedback regarding this issue....my Orthopaedic Surgeon is in a quandary regarding these issues.. We are getting ready to open up a Trauma Center in our ER, so we really need to have these questions answered before all this happens.
Thank you,

Terri D. CPC

 

[AlanPechacek]

Vertebral Fracture as described

We need some guidance, and we also need to know how the choice of codes affects reimbursement.

It is very difficult on our older patients with vertebral compression fractures to decide whether they have pathological fractures due to osteoporosis or traumatic fractures. In many cases, the underlying diagnosis of osteoporosis, steroid-induced osteoporosis, etc., won't be definitively established until after later work-up. For purposes of the trauma program, we do not consider falls from standing height in older individuals to be traumatic fractures. But insurance companies may view it differently. One case in point is the patient we currently have in the hospital. She had an L1 compression fracture due to a fall against a sink from standing height, having been jumped on by a dog, and she has previously diagnosed alleged osteoporosis (studies done elsewhere years ago, so we don't have the studies.) Is this a pathological fracture due to osteoporosis or a traumatic fracture? For purposes of our trauma program, a patient like this wouldn't get in the registry because it would not be considered a traumatic fracture. Also, what are the reimbursement ramifications? If a patient like this needs a kyphoplasty to retard progression of deformity and control pain, do insurance companies and Medicare cover the procedure for both pathological AND traumatic fractures or not????
I would appreciate any and all feedback regarding this issue....my Orthopaedic Surgeon is in a quandary regarding these issues.. We are getting ready to open up a Trauma Center in our ER, so we really need to have these questions answered before all this happens.
Thank you,

Terri D. CPC

This whole issue concerning vertebral fractures is very complicated indeed. After reading your note, I think your criteria of vertebral fractures occurring from a fall from a standing height not being Traumatic far to strict. If patients can fall from a standing height and fracture their hip, pelvis, wrist, shoulder, ankle, etc., then why can't they acquire a vertebral fracture from the same mechanism of injury? From your scenario, the patient in question was jumped upon by a dog (how and how big are uncertain), but with sufficient force as to knock her against her sink (whether she then fell to the floor is not noted), then I would say she had a Traumatic Wedge Vertebral Fracture of L1 (S32.010 _). The patient has an historical diagnosis of Osteoporosis, hopefully confirmed by appropriate studies (DEXA Scan), but maybe confirmable by her medication list if she is on supplemental Calcium and Vitamin D, and/or if she is on a Biphosphonate medication. Regardless, I believe the trauma/mechanism of injury still justifies the designation of Traumatic Fracture. It certainly exceeds the minimum requirement for a Spontaneous, Stress, Fatigue, Insufficiency, etc. Fracture. Without knowing more about the type/cause (Primary or Secondary) Osteoporosis and/or its severity, a supplemental Code of M81.8 Osteoporosis without current pathologic fracture could be added. It is impossible to say to what extent the patient's "Osteoporosis" was a factor in her fracture.
Respectfully submitted, Alan Pechacek, M.D.

 

[mitchellde]

While I tend to agree with the above assessment, the guidelines state:
A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone.

The question for what is posted is whether the patient has known osteoporosis. It seems rather vague on that point. While I do not have osteoporosis, I hav had a big dog jump on me from behind and pushed me onto a sink, but suffered no fracture. Therefore given if there was documentation of osteoporosis, and given the guideline, I would go with the M80 code for osteoporotic fx.

 

[AlanPechacek]

Vertebral Fracture as described

After thinking through this particular case as presented some more, it depends on what aspect has the most weight in the decision making, the injury/traumatic event as describe, which can only be as the patient experienced and described it, + or - the information from witnesses if there were any, versus the "History of Osteoporosis" in the history, but without really knowing the severity of her disease. If you give more weight to the history of the injury, then I would go with the S Code for Traumatic Vertebral Fracture. If you give more weight to the "History of Osteoporosis", then go with the M Code for Osteoporosis with Current Fracture. However I would go with the known facts of the patient's situation. She may have some Osteoporosis, but without the trauma she would not have been the ER with a Compression Fracture of L1. Without the trauma, she would have been at home doing her business, not in the ER.
Therefore, I would still probably go with the Traumatic S Code (S32.010A), which should also be attended by the appropriate External Cause Codes, W Code for being hit by a dog, the Site Code (Y92) for at home, the Activity Code (Y93) probably housekeeping or cooking, and the External Cause Status Code (Y99). These may not be required at this time for standard Medicare, but may be by her insurance, if not Medicare.

Respectfully submitted, Alan Pechacek, M.D.

 

[mitchellde]

I love reading your posts! They are always so well thought out. Now let me give you one more perspective. If not for the osteoporosis would there have been a fx from what was described? So I go from the perspective that since the force of the impact was not described as excessive, like from a bull mastiff or equally sturdy animal, then I think a healthy person spine would not have fractured. So I go with the M80. Having said that, for this particular scenario the presence of the osteoporosis is not confirmed in any way, so without a better hand on that I would be inclined to call it traumatic. However I think I would seek some clarification from the provider.