CCS Prep

Fracture Coding: ICD-9-CM vs. ICD-10-CM

Putting the Pieces Together

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As the Oct. 1, 2013, ICD-10-CM/PCS transition looms, coders should begin to familiarize themselves with the new classification system. Most healthcare providers, whether hospital-based, in a physician office or clinic, or other site will use a multi-faceted approach, with a combination of formal training and other more casual training exercises. This article is an example of that type of training and will provide a short comparison of a very commonly coded type of diagnosis: the fracture.

The first major difference between the ICD-9-CM and ICD-10-CM fracture codes is that in ICD-10, the injury codes (primarily found in the S-codes) are arranged by body part rather than by type of injury. For instance, all injuries to the shoulder and upper arm, including contusions, superficial injuries, open wounds, fractures, dislocations and sprains, crushing injuries, etc, are all located together in code range S40 - S49. As a result, the coder will be utilizing a completely different code range in ICD-10-CM for each different body part fracture.

For the purposes of this article we will be referencing category S42 Fracture of shoulder and upper arm. Our patient record includes documentation of an initial emergency department (ED) visit for a greenstick fracture of the shaft of the right humerus. The ICD-9-CM alphabetic index indicates the following:



                     shaft  812.21

                          open   812.31

A review of the tabular list at subcategories 812.2 and 812.3 substantiates that code 812.21 is the appropriate code; a greenstick fracture is, by definition, a closed fracture. There is a total of one code available for this injury.

The ICD-10-CM alphabetic index indicates the following:




                          greenstick   S42.31-

Whenever a dash (-) appears at the end of a code in the index, it indicates that at least one additional character is required. A review of subcategory S42.31 reveals a total of three codes for greenstick humeral shaft fractures, differentiated by laterality. Our documentation specified that the injury involved the right arm; S42.311 is most appropriate. But the coder must review all instructional notes in the category. At category S42, the following instructions appear:

The appropriate 7th character is to be added to all codes from category S42.

A          initial encounter for closed fracture

B          initial encounter for open fracture

D         subsequent encounter for fracture with routine healing

G         subsequent encounter for fracture with delayed healing

K         subsequent encounter for fracture with nonunion

P          subsequent encounter for fracture with malunion

S          sequela

It's obvious that a wealth of information can be captured with the addition of these 7th characters, which are required on all fracture codes; similar 7th character extensions are required on most injury codes. Our documentation is for an initial encounter so our choices would be limited to characters "A" or "B." However, there is an additional instructional note at subcategory S42.31: "Note: 7th character B is not applicable to codes under subcategory S42.31," which substantiates the fact that greenstick fractures cannot be classified as open fractures and the correct 7th character for our case is "A." The final code assignment in ICD-10-CM is S42.311A.

A review of the 7th characters above shows that the coder will no longer have to worry about assigning V-codes for either aftercare or late effect-related encounters. Data will be collected for each specific type of injury or fracture, clearly differentiated by type of encounter.

In ICD-9-CM there was one code for fracture nonunion and one for fracture malunion. To accurately review data, the secondary code was necessary but was not always as specific as the initial injury code. The subsequent encounter extensions are to be assigned when the patient is receiving treatment during the recovery phase of the injury, such as when seen for a cast change. Extension S (sequela) is to be assigned when a patient is seen for a complication that arises after the initial injury has healed.

For example, if there is a mechanical complication of an internal fixation device a year after it was placed, the code for that complication would be sequenced first, and then a code reflecting the original injury, with a 7th character of "S" for the sequela, would be assigned. The "S" character replaces the late effect categories (905 - 909) in ICD-9-CM. As a result, data will be much more specific and clinicians will be able to track sequela (late effects) back to each specific type of injury. Coders should also be aware that, like the current V-codes for aftercare in ICD-9-CM, there are Z-codes in ICD-10-CM that represent aftercare. However, they are not to be assigned for aftercare involving an injury. The appropriate 7th character (usually "D") should be assigned with the code representing the injury itself.

Before assigning our S42.311A code, a review of the ICD-10-CM tabular list for humeral shaft fractures reveals that instead of only two available codes (as were available in ICD-9), there are now  39 codes, differentiated by laterality and by specific fracture type, such as greenstick, transverse, oblique, spiral, comminuted or segmental. Our documentation must be specific in order to assign the most appropriate code for the injury.

There are three open fracture categories that have expanded 7th character extensions that indicate a more specific classification. These characters represent the Gustilo open fracture classification (types I, II and III) for extremities and identify the severity of the open fracture by classifying the degree of soft tissue injury, thereby helping to determine open fracture prognosis. The additional extensions for categories S52 (Fracture of forearm), S72 (Fracture of femur), and S82 (Fracture of lower leg, including ankle) are:

B    Initial encounter for open fracture type I or II or initial encounter for open fracture NOS

C    Initial encounter for open fracture type IIIA, IIIB, or IIIC

E    Subsequent encounter for open fracture type I or II with routine healing

F    Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing

H    Subsequent encounter for open fracture type I or II with delayed healing

J     Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing

M    Subsequent encounter for open fracture type I or II with nonunion

N   Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion

Q   Subsequent encounter for open fracture type I or II with malunion

R    Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

One last important rule about 7th characters: they must always be assigned in the 7th character position, even if the code as constructed does not contain six characters. If there are not enough (six) characters, the coder must assign what's been designated as a "place-holder" character, which is an "x."  An example of a code using this place-holder character is:

S42.91xA  Fracture of right shoulder girdle, part unspecified, initial encounter for closed fracture

Obviously this is a good example of the specificity in ICD-10-CM that will require more detailed documentation in the medical record. Many hospitals, particularly in emergency departments (EDs), use preprinted forms that are specific to certain types of injuries, such as fractures. It's not too early to be reviewing these forms and updating them with specific information, such as the open fracture types listed above. By taking a proactive approach, coders and coding management can lessen the overwhelming nature of moving to a classification system with so many more choices.

Coders should review the ICD-10-CM Draft Official Guidelines for Coding and Reporting, section C.19.a for information related to code extensions and section C.19.c for coding traumatic fractures. After review, test yourself with the following quiz:


1) When a dash (-) appears at the end of an ICD-10-CM code in the alphabetic index, it means that:

a) it is complete

 b) the coder may append another character if desired

c) at least one additional character is required

d) another code is required, in addition to the one indexed

2) If a patient has a late effect type of complication following a healed injury, a code for the late effect (sequela):

a) should not be assigned; it's included in the 7th character of the injury code

b) should be coded separately and sequenced first

c) should be coded separately but sequenced as a secondary condition, after the injury code

d) should be coded separately but sequencing depends on the circumstances of the encounter


This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, hospital solutions, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix.

Coding Clinic is published quarterly by the American Hospital Association.
CPT is a registered trademark of the American Medical Association.



1) c. As much detail as possible is included in the index, but in many cases the coder must append at least one additional character to the end of the code in question that appears with a dash (-) at the end of it.

2) b. Refer to official coding guideline C.19.a: "The specific type of sequela (e.g., scar) is sequenced first, followed by the injury code."

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