Each year millions of Americans suffer fracture injuries and are treated in both inpatient and outpatient settings. The type of fracture suffered can vary significantly, as can the codes required to describe it accurately. Before coding any fracture, it's important to classify the type of fracture appropriately, keeping in mind the type of encounter and whether or not it is the initial treatment episode of care or a follow-up visit.
Open or Closed
Most commonly, fractures are documented as either "open" or "closed." A closed fracture is one in which skin is intact at the site of fracture. Other terms may be included that also describe closed fractures, but the code assignment remains the same. Some of these terms include: comminuted; depressed; elevated; fissured; fracture NOS; greenstick; impacted; linear; simple; slipped epiphysis; and spiral.
Some coders want to assign an open fracture code when the term "comminuted" is included in the documentation, but comminuted only describes a fracture in which the bone is broken into more than two fragments, but is still closed.
An open fracture indicates the skin is perforated and there is an open wound communicating with the site of the fracture. Note that the opening in the skin must communicate with the fracture site to be classified as an open fracture. In some cases the documentation may indicate the patient has a fracture and also has a laceration at the fracture site. But if the laceration is superficial and doesn't communicate with the fracture, the two should be classified separately, with one code for a closed fracture and another for a laceration. There are other terms associated with open fractures that may appear in the physician documentation, including: compound; infected; missile; puncture; and with foreign body.
Any fracture that is not described as either open or closed should be classified as a closed fracture. The coder should also know anatomy and keep a reference nearby to accurately define the site of the fracture. Keep in mind that the terms "condyle," "coronoid process," "ramus" and "symphysis" refer to a portion of the bone described, not the name of the bone itself. For example, a fractured condyle describes a rounded articular surface at the extremity of a bone and may be located on the humerus, femur or tibia. The coder must ascertain exactly which bone is fractured; if the physician statement, radiology report or other physician documentation does not include this specific information, the coder should query the physician before coding.
Multiple injuries should be coded separately whenever possible, and if a fracture is treated surgically it should be sequenced before other injuries for which the treatment is less complex. Multiple unilateral or bilateral fractures of same bone(s) but classified to different fourth-digit subdivisions (bone part) within the same three-digit category are coded individually by site. Also, multiple fracture categories 819 and 828 classify bilateral fractures of both upper limbs (819) and both lower limbs (828), but without any detail at the fourth-digit level other than open and closed type of fractures.
Two final diagnostic scenarios that should be discussed relate to fracture malunions and nonunions. Coding Clinic, 2nd Quarter 1994, pp. 3-7 defines them in this way:
"Malunion (code 733.81, Malunion of fracture) implies that bony healing has occurred but the fracture fragments are in poor position. Treatment of a malunion, in general, involves the surgical cutting of the bone (osteotomy), repositioning the bone, and usually the addition of some type of internal fixation with or without bone graft. Malunions are frequently diagnosed during a fracture's healing stages. Many malunions may be left without surgical interventions in hopes that the patient will have no functional problems. Surgery usually results from some functional disability or pain as a result of the less than anatomical position of the bones."
"Nonunion (code 733.82, Nonunion of fracture) implies that no healing has occurred between fracture parts. Treatment of a nonunion, in general, involves opening the fracture, scraping away the intervening soft tissue (usually scar tissue) and doing a partial debridement of the bone end with repositioning of the bone. Usually, some type of internal fixation and bone grafting is also performed. The treatment of a nonunion is more complicated and difficult to perform than treatment of a malunion."
Don't forget that a diagnosis code from the range of codes for Late Effects of Fractures (905.0 - 905.5) should also be assigned as a secondary diagnosis for malunions or nonunions. The guidelines indicate that these codes may be assigned at any time after the acute injury.
Review the Guidelines
Coders should carefully review the information on coding fractures in the ICD-9-CM Official Guidelines for Coding and Reporting; refer to section I.C.17.b. The most notable guideline related to fracture coding involves the episode of care. The acute fracture codes (800-829) should only be assigned while the patient is receiving active treatment for the fracture, which includes the following:
• emergency department (ED) encounter
• surgical treatment
• Evaluation & Management (E&M) by a new physician
Once the patient has completed the active treatment phase of his/her care, any additional treatment should be reported with a code from range V54.10-V54.19, Aftercare for healing traumatic fracture. This includes encounters for such things as cast or splint changes, or injury and healing evaluations. Note that these V codes are separate from those related to aftercare involving orthopedic fixation devices (V54.0X) and aftercare following surgery for injury and trauma (V58.43), which is excluded from the V54.1X codes unless the patient is receiving aftercare for both a healing fracture and after surgery for other injuries.
Also note that pathologic fractures should not be reported with the same codes as traumatic fractures. Acute pathologic fractures should be assigned to a code from the 733.1X code range. Aftercare for healing pathologic fractures are assigned to codes V54.20-V54.29. For further guidelines related to these codes, refer to Coding Clinic, 4th Quarter, 2002, p. 78. After review, test your knowledge with the following questions:
1. A 54-year-old patient was previously treated by external fixation for a Grade II left tibial fracture. There is now nonunion of the left proximal tibia and she is admitted for open reduction of tibia with bone grafting. What are the correct diagnosis codes?
a. 733.82, 905.4
b. V54.16, 733.82
c. 823.00, 905.4
d. 823.00, 733.82
2. A 60-year-old patient sustained a comminuted left calcaneal fracture after falling from a ladder. Initial ED treatment consisted of diagnostic radiology studies and surgical ORIF was performed 9 days later. The patient now presents to the orthopedic clinic for evaluation and cast change. What are the correct diagnosis codes?
a. 825.0, E881.0
b. 825.0, V58.43
c. V58.43, V54.19
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, facility solutions, Ingenix, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix (www.ingenix.com).
CPT is a registered trademark of the American Medical Association.
1. a. The diagnosis was a nonunion of the originally repaired tibial fracture; the nonunion code (733.82) should be assigned as the first-listed code, along with 905.4 for a late effect of fracture. The acute fracture code is inappropriate, as is the aftercare code.
2. d. The patient has completed the acute fracture treatment phase; acute fracture code 825.0 is inappropriate. Aftercare code V58.43 is unnecessary since the aftercare of a traumatic fracture of the foot (V54.19) is the only aftercare being provided. Code V58.43 excludes any codes from V54.1X unless additional injuries are assessed.