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Open vs Closed Reduction

  1. #1
    Default Open vs Closed Reduction
    Medical Coding Books
    I am looking for some help on an Inpatient chart I am working on. I have a patient with a intertrochanteric fracture. The procedure listed is "Open Reduction internal fixation right hip intertrochanteric fracture, use of fluoroscopy".

    PROCEDURE: After sedation and prepping the hip fracture was reduced and this was checked in the AP and lateral planes. Next the right lower extremity was prepped and draped in a sterile manner. Upon completion of prepping and draping, a longitudnal incision was made starting at the tip of the greater trochanter. A guide pin was introduced at the tip of the greater trochanter and reamed in to place. Femoral nail was then passed. A second incision was made laterally for the helical blade. The pin was checked in the AP and latearl planes and was flet to be in satisfactory position. The lateral cortex was then reamed and a helical blade was then impacted into place and compression was set followed by the set screw being placed. A third incision was made distally and this was for the distal locking screw. This was passed without complication.

    I was under the impression that this is a CLOSED reduction followed by internal fixation since the reduction took place prior to incision being made. I sent a query to the physician and he tells me it was really OPEN reduction.

    Any help would be greatly appreciated!

  2. Default
    That note is insufficient documentation for open reduction of fractured hip.

  3. #3
    Nashville AAPC Chapter
    The MD made an incision, this concludes as an OPEN procedure.....take a look at 27245 and see if you think this fits your description.

  4. #4
    Thank you for your help. I will go with Open Reduction on this case since that is what the physician insists that it is.

    Thanks again!

  5. #5
    Columbia, MO
    If you look in the CPT book at the begining of the chapter for musculoskeletal they have the definition of open reduction, in there it states that if the provider makes an incision remote from the fracture site to insert an intemeduliary rod then it is an open procedure. Therefore he has documented for an open procedure

    Debra A. Mitchell, MSPH, CPC-H

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