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 procedure performed on a fracture, it's important to classify the type of fracture appropriately.
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 the following: 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 that 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 that 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. These include: 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 higher than other injuries for which the treatment is less complex. 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 diagnosis codes for Late Effects of Fractures (905.0905.5) should also be assigned for malunions or nonunions. The guidelines indicate that these codes may be assigned at any time after the acute injury. After accurately defining the type of fracture, i.e., the diagnosis, the coder can then review the type of procedure performed. This discussion will include both ICD-9-CM procedures (for inpatient cases) and CPT procedures (for outpatient cases).
The goal of fracture treatment is to attain a secure union and restore normal function as quickly and as safely as possible. The type of fracture treatment chosen depends upon the general condition of the patient, the presence of associated injuries, and type and location of the fracture. In general, fracture treatment typically consists of two treatments:
Reduction or manipulation of the bone fragments to as near proper anatomic position as possible; or
Stabilization (fixation or immobilization) until healing is sufficient to prevent displacement.
Physician documentation most often in-cludes information related to either "open" or "closed" treatment. The coder should not confuse this description of the type of procedure with the "open" and "closed" information that describes the type of fracture. The two will not necessarily match. It is not uncommon for a closed fracture to require open treatment. The two should be coded separately and independently.
Closed reduction of a fracture (code 79.0X, Closed reduction of fracture without internal fixation and code 79.1X, Closed reduction of fracture with internal fixation) indicates that the surgeon does not make an incision through the skin and subcutaneous tissue to expose the fracture. The treatment involves a manipulation of the fractured bone and typically involves some type of radiological guidance or before and after radiology exams to ensure proper alignment of the fractured bone. Closed reduction may include internal fixation, but if no incision is made to expose the fracture, it is still coded as a closed reduction. In this procedure, small incision(s) for placement of the internal fixation device may be made. Internal fixation devices include pins, wires, screws, plates and intramedullary nails. Placement of internal fixation devices immobilize the fracture site; it is not a form of fracture reduction. The most challenging task for new coders is differentiating between these small incisions made only for internal fixation and those incisions that indicate an open reduction procedure. The coder must keep in mind that internal fixation does not always require direct exposure of the fracture site. The use of radiological guidance for placement of the fixation device is another clue that coders can use to ensure appropriate assignment of closed reduction, internal fixation codes. A fracture may be fixated without a reduction procedure being performed, in which case code 78.5X should be assigned.
Open reduction of a fracture (code 79.2X, Open reduction of fracture without internal fixation and code 79.3X, Open reduction of fracture with internal fixation) involves manipulative correction of a fracture to anatomical position after incision into the fracture site. Open reduction of a fracture involves deliberate exposure of the bone by the surgeon for the purpose of restoration of the proper anatomy. Open reduction and internal fixation, abbreviated as ORIF, is a very commonly performed procedure for fractures but the coder should ensure that the incision was made to expose the fracture for treatment.
External skeletal fixation (codes 78.10-78.19, Application of external fixation device) is another fracture treatment that may be documented in the medical record. This procedure involves the insertion of percutaneous pins proximal and distal to the fracture and an application of a frame that connects the pins externally. The pins are located internally except for the portion to which the frame is connected. The frame is located external to the body. These devices can be used to hold a reduced fracture or to assist the surgeon in reducing a fracture. Note that the ICD-9-CM instructional notes under the "Reduction of fracture and dislocation" category indicates that the external skeletal fixation codes may be assigned in addition to the codes describing fracture reduction.
When assigning CPT codes for fracture treatment, the coder should remember that although the definitions of "open" and "closed" treatment remain the same, CPT describes reduction procedures as "manipulation." Manipulation is defined as the attempted reduction or restoration of a fracture to its normal anatomic alignment by the application of manually applied forces.
The CPT manual is constructed completely differently than ICD-9-CM volume 3, so the coder must be aware that all reduction/manipulation services are not in one location with the fracture site designated by the use of a specific fourth digit. In CPT the fracture treatment codes are located throughout the musculoskeletal chapter in the "Fracture and/or Dislocation" sections related to each anatomical site. This means that there are many more specific code descriptions in CPT and the coder must carefully differentiate between these procedures. For example, if a patient is treated for a forearm fracture, there are potentially seven ICD-9-CM codes available, 79.02 through 79.62 (excluding additional codes for percutaneous skeletal fixation). In the CPT "Fracture and/or Dislocation" subsection of the "Forearm and Wrist" section, there are potentially at least 20 different code assignments available (beginning at code 25500), based upon whether or not both the radius and ulna were involved, which portion of the bone(s) were involved, open or closed treatment was performed, manipulation was involved or percutaneous skeletal fixation was utilized. The coder must have the operative report with the specific surgical techniques employed to accurately assign the most appropriate CPT code(s).
The CPT manual also includes separate codes for malunion or nonunion fracture treatment for most anatomical sites. For instance, in the example above related to a radius and ulna fracture, if the patient returned several months later with a malunion and was treated surgically, there are several CPT codes available, beginning with code 25400, that specifically indicate nonunion or malunion repair. In the ICD-9-CM coding system, the procedure code assigned is the one that describes the procedure performed. There are no specific procedure codes that indicate treatment exclusively for malunion or nonunion. There is an "Includes" note under code 78.4: "Repair of malunion or nonunion fracture NEC" but this should only be assigned if the specific treatment involved (fixation, osteotomy, bone graft, etc.) is not specified.
Coders should also be aware that if an open fracture is present and is debrided, there are specific codes for this procedure. In ICD-9-CM, code 79.6X represents debridement of open fracture and should be assigned instead of the much more commonly assigned code 86.22, Excisional debridement of wound, infection, or burn. There are also three CPT codes available for fracture debridement: 11010, 11011 and 11012, which are differentiated by the extent of the debridement procedure. Note that in CPT Assistant, April 1997, pp. 10-11, the guidelines indicate that in a traumatic fracture injury, if the skin is damaged extensively, causing massive involvement of the surrounding soft tissues and requires significant debridement, but the wound is not involved down to the fracture (and so not classified with the ICD-9 diagnosis code as an open fracture), it is appropriate to report CPT code 11010-11012 (as appropriate) to describe the debridement performed. Coders may also want to review CPT Assistant, March 1997, pp. 1-3, which details the appropriate use of the fracture debridement codes, including the assignment of multiple debridement codes. The assignment of these codes, whether singly or in combination with other CPT codes is dependent upon the specific circumstances of the injury itself and the extent of treatment required.
Another important consideration in-volves splinting, strapping and casting procedures. In CPT, the splinting, strapping and casting service is included in any more invasive surgical procedure and is not reported separately. When this type of service is performed in the emergency department setting for comfort and stabilization purposes only, and the patient is to follow-up with another physician for definitive treatment, only the splinting, strapping or casting service is reported. Do not assign a CPT code for fracture treatment without manipulation. The only time these codes should be assigned is when the entire fracture treatment (meaning no other follow-up is required) is performed on the episode of care in question and no reduction/manipulation service is provided.
In summary, the accurate assignment of diagnosis and procedure codes for fractures and their associated treatment depends upon clear understanding of the anatomic sites and extent of the injuries and of the various treatment modalities available. After review of the Coding Clinic and CPT Assistant references related to fractures and their treatment, take the following quiz to test your knowledge.
1. A patient was admitted with a mitre saw injury, resulting in a multiple phalanx open fracture of the right long finger with bone loss and tendon laceration. A debridement of the long finger was performed with shortening and fixation repair of fracture site. The tendon lacerations were repaired and debrided of bone fragments. What diagnosis and ICD-9-CM procedure codes should be assigned?
a. 816.00, E919.4, 86.22, 79.14
b. 816.13, E919.4, 79.64, 78.59
c. 816.13, E919.4, 79.64, 82.11
d. 817.13, E919.4, 79.34, 82.45
2. A patient is seen in the hospital's outpatient surgical area with a diagnosis of a displaced comminuted fracture of the lateral condyle, right elbow. An ORIF procedure was performed, which included the following techniques. An incision was made in the area of the lateral epicondyle and this was carried through subcutaneous tissue, and the fracture site was easily exposed. Inspection revealed the fragment to be rotated in two places about 90 degrees. It was possible to manually reduce this quite easily, and the manipulation resulted in an almost anatomic reduction. This was fixed with two pins driven across the humerus. The pins were cut off below skin level. The wound was closed with plain catgut subcutaneously and 5-0 Nylon for the skin. Dressings and a long arm cast were applied. Which of the following is the correct ICD-9-CM and CPT code assignment?
a. 812.52, 24577, 29065, 79.32
b. 812.42, 24579, 29065, 79.52
c. 812.42, 24579-RT, 79.31
d. 812.52, 24579-RT, 79.31
3. A 47-year-old patient was previously treated by external fixation for a Grade III left tibia fracture. There is now nonunion of the left proximal tibia and he is admitted for open reduction of tibia with bone grafting. Approximately 30 grams of cancellous bone was harvested from the iliac crest. The fracture site was exposed and the area of nonunion was osteotomized, cleaned and repositioned. Interfragmentary compression was applied and three screws and the harvested bone graft was packed into the fracture site. What are the correct codes for this diagnosis and procedure?
a. 733.82, 905.4, 27724-LT, 79.36, 78.07, 77.79
b. 823.00, 905.4, 27724-LT, 79.36, 78.07
c. 733.81, 905.4, 27720-LT, 79.36, 78.07, 77.79
d. 733.82, 905.4, 27720-LT, 79.36, 78.07
4. A Grade 1, high velocity open right femur shaft fracture was incurred when a 15-year-old female pedestrian was hit by a car. She was taken to the operating room within four hours of her injury for thorough irrigation and debridement including excision of devitalized bone. The patient was then reprepped, redraped and repositioned. Intermedullary rodding was then carried out with proximal and distal locking screws. What are the correct codes for this diagnosis and procedure?
a. 821.01, E814.7, 27507-RT, 79.35
b. 821.11, E814.7, 27506-RT, 11012, 79.35, 79.65
c. 821.11, E814.7, 27509-RT, 11044, 79.25, 86.22
d. 821.01, E814.7, 27507-RT, 79.35, 79.65
Coding Clinic for ICD-9-CM Official Coding Guidelines, effective 10/1/02: Section C.17 Injury and Poisoning, subsection 8. Coding of Fractures.
ICD-9-CM 6th Edition; Guidelines in Chapter 17 Injury and Poisoning at Fractures (800-829).
Coding Clinic, 2nd Quarter 1994, pp. 3-7.
CPT Assistant, March 1997, pp 1-3.
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services, HSS Inc. (http://www.hssweb.com/), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Coding Clinic is published quarterly by the American Hospital Association.
CPT is a registered trademark of the American Medical Association.
1. b. The open fractures were specified as involving multiple phalangeal sites; code 816.13 is most appropriate. The fracture was debrided; code 79.64 is appropriate. See the EXCLUDES note under code 86.22 and do not assign it for this case. No fracture reduction or manipulation procedure is documented, but internal fixation is; assign 78.59. Do not assign an additional code for the tendon debridement or bone shortening procedures. These procedures are an integral part of the total procedure performed and should not be coded separately.
2. c. Diagnosis code 812.52 describes an open fracture, which is not documented; code 812.42 is the appropriate diagnosis. CPT code 24577 describes a closed reduction procedure; this was an ORIF, most accurately described by code 24579. Code 29065 should not be assigned with a fracture care code, since casting is included in the initial fracture treatment code. ICD-9-CM procedure code 79.52 is for open reduction of a radius/ulna separated epiphysis, not documented for this case. In this case the humerus fracture was reduced/fixated so code 79.31 is the most appropriate code.
3. 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. CPT code 27724 is the most appropriate, which describes repair of tibial nonunion with an iliac or other autograft. The ICD-9-CM codes reflect ORIF, excision of the bone graft and application of the bone graft, all required for appropriate code assignment.
4. b. The procedure involved debridement of an open fracture, including bone; codes 11012 and 79.65 are most appropriate. Intramedullary rodding was also performed; codes 27506 and 79.35 describe this procedure most accurately. Do not assign codes 11044 or 86.22 for this type of debridement procedure. The diagnosis involved an open fracture of the femoral shaft; code 821.11 is most accurate.