April 2003 Bulletin

Accurately code hip fractures

Learn instructions and examples

By Margie Scalley Vaught, CPC, CCS-P, MCS-P and reviewed by Alan H. Morris, MD

This is the second piece of a two-part series of articles that addresses ICD-9 coding related to injuries. This article focuses on instructions and examples of orthopaedic fracture coding related to hip fracture, osteoporosis and falls.

In May 2001, the AAOS and representatives of other organizations that provide care for patients with hip fractures convened the National Consensus Conference in Washington, D.C., on the topic of "Improving the Continuum of Care for Patients with Hip Fracture."

This article will describe proper coding as identified at the National Consensus Conference. The participants made recommendations to accomplish the goals of improving the care of patients with hip fracture in areas of research, education, improved communication and reimbursement/coding issues.

Among the recommendations to improve proper coding for research and patient follow-up, the attendees of the conference identified the following needs:

The E-codes to identify a history of falls and related external causes were explained in the December 2002 issue of the Bulletin. For further information, see other resources cited at the end of that article.

Additionally, secondary ICD-9 diagnoses can be provided to fully identify and describe many of the problems–specifically, pre-existing co-morbid conditions (i.e., osteoporosis) and/or pre-existing conditions that predisposed the patient to a pathologic fracture (e.g., tumor or osteoporosis).

Alerting the third-party payor on your insurance form that a patient sustained a pathological fracture due to osteoporosis, identifies risk factors and raises the possibility that this particular patient’s care can become extended or complicated. This can at times support the medical necessity for longer hospital stays, frequency of home care and/or extended care needs. It also lets the carrier know the mechanism of how the fracture was sustained. Reporting secondary conditions also is helpful in research coding.

Currently ICD-9-CM classifies osteoporosis as senile or postmenopausal, idiopathic and disuse or drug-induced.

The American Hospital Association Coding Clinic Reference Notations (http://www.channelpublishing.com/ahacodingclinic.htm) is published quarterly and a good source that will provide the answer to a coding question related to a pathological fracture in a patient with osteoporosis. Following is an example:

After walking out of a nursing home and falling off the curb, an 89-year-old woman, with a history of severe osteoporosis, is admitted to the hospital for a fractured left hip. X-rays show advanced osteoporosis and a comminuted subtrochanteric fracture. Should the fracture be coded as pathological or as the result of trauma?

Answer: This is a clinical question that must be directed to the patient’s physician. Sometimes minor trauma can cause a fracture in an individual with severely diseased bone, and that is called a pathological fracture. Only the physician can determine whether or not the level of injury is in accordance with the degree of trauma suffered by the patient.

If the physician determines that the fracture is due to trauma, then only a code(s) from 800-829, Fractures, would be assigned. A code from category 733.00, Osteoporosis, may also be assigned. The pathological fracture code would not be assigned.

If, however, the physician determines that the fracture is pathological and due to osteoporosis, then code 733.15, Pathological Subtrochanteric Fracture of Femur, and a code from category 733.0X, Osteoporosis, should both be assigned. Code E888.0, other and unspecified fall, may also be assigned.

Examples:

An active patient with a diagnosis of senile osteoporosis falls at home and sustains a trochanteric fracture:

820.20 — Trochanteric fracture, unspecified

733.01 — Osteoporosis, senile

E888.9 — Unspecified fall

E849.0 — Place of occurrence, Home

A patient taking prednisone for rheumatoid arthritis falls while bicycling and sustains a closed fracture at the base of the femoral neck:

820.03 — Base of Neck fracture, femur closed

733.09 — Osteoporosis due to Prednisone

714.0 — Rheumatoid arthritis

E935.6 — Adverse effects of therapeutic use of Antirheumatics

E826.1 — Fall from bicycle

A bedridden nursing home resident with disuse osteoporosis sustains a hip fracture from falling out of bed:

733.14 — Pathologic fracture, hip

733.03 — Disuse osteoporosis

E884.4 — Fall from bed

E849.7 — Place of occurrence, Old people’s home

As with updating CPT codes, ICD-9-CM codes have a similar process.

Petition for new ICD-9-CM codes

To petition for new ICD-9-CM codes, please contact Dan Sung, the AAOS liaison for the CPT/ICD-9 Coding Committee. He can be reached at (847) 384-4320 or via e-mail at sung@aaos.org.

Resources:

ICD-9-CM Expert for Physicians, St. Anthony Publishing, Medicode, Ingenix Companies, Volumes 1 and 2, 2003

Morris A.H., Zuckerman J.D.: National Consensus Conference on Improving the Continuum of Care for Patients with Hip Fracture, J Bone Joint Surg Am 2002 84: 670-674.

Margie Scalley Vaught, CPC, CCS-P, MCS-P, is an independent coding specialist in Ellensburg, Wash. She is also a member of the American Academy of Professional Coders’ National Advisory Board. She can be reached at vaught@kvalley.com.

Alan H. Morris, MD, is past chair of the AAOS Council on Health Policy and Practice. He has more than 12 years of experience with AAOS health policy and payment issues. Dr. Morris can be reached via e-mail at nemomorris@aol.com.

Answers to common coding questions may be addressed in future editions of the Bulletin. Fax (847) 823-8026.


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