Focus on fracture coding changes in ICD-10-CM

The section of codes that expanded most in ICD-10-CM involves orthopedic injuries, especially fractures.

 

In ICD-9-CM, coders may only have two choices for a particular fracture. For example, a fracture of the shaft of the humerus only has two possible ICD-9-CM codes—812.21 for a closed fracture and 812.31 for an open fracture.

 

In ICD-10-CM, fractures of the shaft of the humerus fall under subcategory S42.3-, which includes eight subdivisions that specify the type of fracture, such as greenstick or comminuted. Each subcategory includes three codes to indicate laterality—left, right, or unspecified. Five of the categories further specify whether the code is displaced or non-displaced.

 

All of the codes in subcategory S42.3- require a seventh character to identify the encounter. Coders have seven options when it comes to seventh characters in S42.3-.

 

ICD-10-CM does include two default guidelines for fractures. If a fracture is not documented as displaced or nondisplaced, code it as displaced. If a fracture is not documented as open or closed, code it as closed.

 

The most difficult aspect of coding fractures is that a fracture not documented as displaced or non-displaced is automatically considered displaced, says Kristi Stanton, RHIT, CCS, CPC, CIRCC, AHIMA-approved ICD-10-CM/PCS trainer, AHIMA ICD-10 ambassador, and senior consultant with the Haugen Consulting Group in Denver.

 

“Just know that it is assumed, unless the physician specifically tells us that it’s non-displaced, that that fracture was not in a normal position,” Stanton says.

 

Coders need to make sure that they look at the entire record and all the documentation.

 

“Sometimes, if it’s a really nasty open fracture, they may not really come out and call it an open fracture,” Stanton says. “But as you look at the operative report, you can tell that it really was. Remember to go with your default guideline and that there is no shopping in the ICD-10 index. So you’ve got to go specifically with what the physicians say.”

 

For every fracture, coders will need to identify the bone as well as where on the bone the fracture occurred, says Kim Carr, RHIT, CCS, CDIP, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, AHIMA ICD-10 ambassador, and clinical documentation director for HRS in Baltimore. For example, is the fracture at the head or the shaft, the proximal or distal end?

 

“That’ll be another type of documentation you’re going to need,” Carr says. Coders will also need the laterality and the episode of care. If physicians are not currently providing this information, consider beginning to query now so they become used to providing it before the ICD-10 transition.

 

The seventh character for ICD-10-CM fracture codes denotes the encounter. The specific choices vary by fracture category, so coders need to look at the beginning of the category and section to find which seventh character applies.

 

“First of all, these must be in the seventh character position,” Stanton says. “Some of the codes that we have only have four or five characters, so we use an X as a placeholder.”

All fractures will have the option of three basic seventh character extension options:

 

Be careful not to confuse initial encounter with first visit. “What you really have to look at for the ICD-10 code is whether the patient is receiving active treatment or have they moved on to subsequent treatment,” Stanton says.

 

Active treatment could include surgery, an ED visit, or evaluation and treatment by a new physician. “As long as the patient is receiving active treatment, they get an A,” Stanton says.

A subsequent encounter (seventh character D) includes:

 

A sequela (seventh character S) is exactly like a late effect in ICD-9-CM. “Whatever was a late effect in ICD-9 is now a sequela in ICD-10,” Stanton says.

 

Some fracture categories, such as S42 (fracture of shoulder and upper arm) include these seventh character choices:

 

Three categories of fractures feature even more seventh character possibilities. For categories S52 (fracture of forearm), S72 (fracture of femur), and S82 (fracture of lower leg, including ankle), coders will choose one of the following seventh characters:

 

The types for these seventh characters refer to the Gustilo-Anderson classification, which applies to open fractures of the long bones, says Carr.

 

The Gustilo-Anderson classification also captures the severity of open fractures. It groups fractures into three main categories: type I, type II, and type III, which is further divided into three subcategories: A, B, and C.

 

The Gustilo-Anderson categories are defined by three characteristics:

While coders can use the description of an ulcer to code the stage in ICD-10-CM, they cannot use the description of the amount of soft tissue damage to assign a type on the Gustilo-Anderson classification, Carr says. The physician must specifically state the type.

 

ICD-10-CM also includes changes for reporting orthopedic aftercare. In ICD-9-CM, coders report a V code for physical therapy or other aftercare.

 

ICD-10-CM does include a code for orthopedic aftercare —Z47.89 (encounter for orthopedic aftercare). “However, we do not use this code for orthopedic aftercare for injuries,” Stanton says. “What we report instead is the code for the injury with the seventh character for subsequent care.”

 

For example, a patient is admitted to a rehab facility for physical and occupational therapy following an open reduction internal fixation for a fracture of the left intertrochanteric section of the femoral neck.

“Currently in ICD-9, if we were to code this case, it would go to a V57.89 as our principal [diagnosis] and an 820.21 for the intertrochanteric fracture,” Stanton says. This case groups to MS-DRG 945 (rehabilitation with CC/MCC).

 

In ICD-10-CM, coders will report S72.142D (displaced intertrochanteric femoral neck fracture, subsequent encounter for closed fracture with routine healing) and no secondary diagnosis. Code S72.142D groups to the lower-paying MS-DRG 561 (aftercare, musculoskeletal system and connective tissue without CC/MCC).

 

A patient comes into the ED with a fracture of his right clavicle. The coder assigns code S42.021A (displaced fracture of shaft of right clavicle) for the initial visit.

 

The patient returns later with a nonunion of the fracture. “For his subsequent visit, the coder reports S42.021K, which is the same code, but the seventh character is now letting us know that this is a subsequent encounter and he has a nonunion,” Stanton says.

 

The unfortunate patient then suffers post-traumatic shortening of the right clavicle due to a fracture of the clavicle shaft three years ago. Again, the coder assigns the exact same base code, but the seventh character now represents the sequela (S42.012S), Stanton says.

 

What happens when a patient comes in for treatment of malunion of a fracture and has never been seen before for that fracture? “On one hand, you kind of want to go with initial because the patient has never had treatment, but on the other hand, we kind of want to go with that subsequent seventh character because it would specify malunion,” she says.

 

Coding Clinic, Fourth Quarter 2012, instructs coders to report a seventh character A. “The fact that this is the first time that the patient is presenting for treatment takes precedence over the malunion,” Stanton says.

 

Coding for initial versus subsequent malunion can become tricky very quickly, she says. Coders need to carefully read the documentation to determine whether the patient is seeking treatment for the first time for the fracture.

 

“You cannot code a subsequent seventh character if the patient has not presented for treatment before,” Stanton says.