In this blog we will be reviewing ICD-10-CM guidelines for Chapter 19. This chapter is bursting at the seams with guidelines on injuries, burns, adverse effect, poisoning, underdosing and toxic effects. Therefore, I decided to split this post into two parts. Today, we’ll review the coding guidelines for injuries and traumatic fractures.
Most categories in chapter 19 have 7th character values, which describe the type of encounter and include:
A - Initial encounter. This 7th character should be used when a patient is receiving “active treatment,” regardless of the number of visits or services are provided. It does not mean that this is the first visit for a new physician, as is commonly misunderstood.
D – Subsequent. This 7th character should be used after the patient has completed active treatment and is receiving “route after care” for the injury during the healing / recovery phase. Routine aftercare may include removal of cast or internal/external fixation device and follow-up visits. It is not appropriate to include an aftercare Z code with an injury when this 7th character is available in the code selection.
S – Sequela. This 7th character should be used when conditions that arise as a direct result of a condition, such as scar formation after a burn, a contracture as a result of a shoulder fracture, or chronic pain. These conditions are commonly referred to as “late effect.” The specific sequela or late effect condition should be sequenced first, followed by the injury code with the 7th character S.
Injury codes begin with either alpha character S, which includes types of injuries related to single body regions, or the alpha character T, which covers injuries to unspecified body regions, as well as poisonings and certain other consequences of external causes.
Let’s review this by using a few examples:
- A 22-year-old female who was walking on the beach barefooted, cut her foot on broken glass. She has a 2 cm laceration on the left heel, with glass fragments. The appropriate ICD-10-CM code for this patient is S91.322A – Laceration with foreign body, left foot, initial encounter.
- A 63-year-old male with a whiplash neck injury from an auto accident last summer. He now presents in the office for follow-up on chronic neck pain at the same site. The appropriate ICD-10-CM codes for this patient are G89.21 – Chronic pain due to trauma and S13.4XXD – sprain cervical spine, subsequent encounter.
Bone fractures are common. Over 1 million people in the US are annually diagnosed with traumatic factures. The human body has 270 bones at birth, then as we age into adulthood, this total decreases to 206 bones. That’s 206 different locations where a facture can occur! There are also many different types of fractures. It is important to understand the location of the fractured bone, and the type of facture to assign the appropriate ICD-10-CM code. Let’s review the common fracture types that a coder may see in the medical record:
- Avulsion fracture - A muscle or ligament pulls on the bone, fracturing it.
- Comminuted fracture - The bone is shattered into many pieces.
- Compression (crush) fracture - Generally occurs in the spongy bone in the spine. For example, the front portion of a vertebra in the spine may collapse due to osteoporosis.
- Fracture dislocation - A joint becomes dislocated, and one of the bones of the joint has a fracture.
- Greenstick fracture - The bone partly fractures on one side but does not break completely because the rest of the bone can bend. This is more common among children, whose bones are softer and more elastic.
- Hairline fracture - A partial fracture of the bone. Sometimes this type of fracture is harder to detect with routine x-rays.
- Impacted fracture - When the bone is fractured, one fragment of bone goes into another.
- Intraarticular fracture - Where the break extends into the surface of a joint.
- Longitudinal fracture - The break is along the length of the bone.
- Oblique fracture - A fracture that is diagonal to a bone's long axis.
- Pathological fracture - When an underlying disease or condition has already weakened the bone, resulting in a fracture (bone fracture caused by an underlying disease/condition that weakened the bone).
- Segmental fracture – In this fracture, the bone breaks into two or more large pieces at the fracture site. This type frequently causes soft tissue injury and is usually the result of high-energy trauma.
- Spiral fracture - A fracture where at least one part of the bone has been twisted.
- Stress fracture - More common among athletes. A bone breaks because of repeated stress and strain.
- Torus (buckle) fracture - Bone deforms but does not crack. More common in children. It is painful but stable.
- Transverse fracture - A straight break right across a bone.
In addition to the specific anatomical site (location) and type of fracture, a coder needs to look for specific documentation as to whether the fracture is displaced or not, the laterality, if the fracture treatment is routine versus delayed healing, nonunion, or malunions and, finally, the type of encounter (initial, subsequent, sequela) has to be understood in order to assign the appropriate code. Like injuries, the 7th character for fractures describes the type of encounter and include:
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
Per the ICD-10-CM guidelines, when the medical record documentation of a fracture does not indicate if the fracture is displaced or nondisplaced, the coder should assume the fracture is displaced. Similarly, when the medical record documentation of a fracture does not indicate if the fracture is open or closed, the coder should assume the fracture is closed.
Now, let’s review what we’ve learned by using an example:
- A 35-year-old male patient injured his right leg during a fall from a tree, after examination and review of X-ray, he is diagnosed with a fracture of greater trochanter of the right femur. The appropriate ICD-10-CM code for this fracture is S72.111A - Displaced fracture of greater trochanter of right femur, initial encounter for closed fracture.
The ICD-10-CM guidelines add another layer of complexity to coding for opened fractures. Some fracture categories provide the 7th characters to designate the specific type of open fracture based on the Gustilo Open Fracture Classification system. This system classifies open fractures into three major categories, depending on the mechanism of the injury: soft tissue damage and degree of skeletal involvement. The classes are I, II, and III, with the third class being further subdivided into A, B, or C. these subdivided classes are used to identify the severity of the soft tissue damage, fracture healing, infection, and to determine prognosis. 7th characters available for these open fractures include:
B - Initial encounter for type I or II
C - Initial encounter for IIIA, IIIB, or IIIC
E - Subsequent encounter for I or II with routine healing
F - Subsequent encounter for IIIA, IIIB, or IIIC with routine healing
H - Subsequent encounter for type I or II with delayed healing
J - Subsequent encounter for type IIIA, IIIB, or IIIC with delayed healing
M - Subsequent encounter for type I or II with nonunion
N -Subsequent encounter for type IIIA, IIIB, or IIIC with nonunion
Q - Subsequent encounter for type I or II with malunion
R - Subsequent encounter for type IIIA, IIIB, or IIIC with malunion
Now, let’s review this through another example:
- A 50-year-old female patient is seen in the emergency department following an MVA. She was attempting to exit her car when it was struck by another car resulting in an impact on her right forearm. Her forearm was pinned resulting in a large open forearm wound. On x-ray the ulna and radial bones show multiple fractures. She is diagnosed with a displaced transverse fracture of left ulna and open fracture of radial shaft. The appropriate ICD-10-CM codes are: S52.351C – displaced fracture of the radius shaft, right arm in initial encounter for open fracture, type IIIA, IIIB, or IIIC and S52.221C – displaced transverse fracture of the right ulna, initial encounter for open fractur type IIIA, IIIB, or IIIC.
In conclusion, the code assignment for fractures is bit complex but with proper documentation and use of set guidelines assigning correct ICD-10-CM code becomes easier. Be sure to check back next week, when we’ll release Part 2 of Chapter 19 ICD-10-CM Guidelines.