October 1998 Bulletin

How to code for traumatic fractures

Review of ways to code for multiple fractures, sites with or without sufficient documentation

By Bonnie Schreck

Codes for traumatic fractures are located in the injury and poisoning section (800-999) of ICD-9-CM. When selecting a diagnosis code for a traumatic fracture(s), the fourth digit in an ICD-9-CM code will determine whether it is an open or a closed fracture. An open fracture code is used when the skin has been punctured or lacerated.

The following types of fractures are considered open: compound, infected, missile, puncture and with foreign body. Closed fractures are where the skin stays intact, or is not exposed to the external environment. Examples of closed fractures are: comminuted, depressed, elevated, fissured, fracture, greenstick, impacted, linear, march, simple, slipped epiphysis or spiral. If a fracture has not been documented as open or closed, it should be coded as closed. If a diagnostic statement has indicated the fracture as both open and closed, it should be coded as open.

According to ICD-9-CM, principles of multiple coding of injuries should be adhered to (when applicable) when coding for multiple fractures. There are combination categories available for use when insufficient detail is documented as to the nature of the patient's condition (e.g., code 815.09, multiple sites of metacarpus). If detailed information is provided, then each fracture should be coded separately (e.g., 815.02, base of other metacarpal bone, and 815.04, neck of metacarpal bone). When multiple anatomical sites are provided in the descriptions of the codes, the word "with" indicates involvement of both anatomical sites and the word "and" indicates involvement of either or both for the sites. Example:

813.18Radius with ulna, upper end [any part]
813.17Other and unspecified fractures of proximal end of radius, (alone)

Generally, when coding for multiple fractures, the most severe fracture should be listed as the primary diagnosis, as long as the physician is treating each and every diagnoses. If a physician treated a patient who sustained an intertrochanteric fracture of the left femur, an open fracture of the shaft of the right radius and ulna, and a closed fracture of the fifth and sixth ribs, all of these may be coded in the following sequence:

820.31Open intertrochanteric fracture of the left femur
813.33Open right radial and ulnar fracture of the shaft
807.02Closed fifth and sixth rib fracture on the left side

For fracture dislocations at the same anatomical site, only the fracture code is reported. Fractures are commonly dislocated as the result of the injury. When looking up the main term "fracture" in the Alphabetic Index of ICD-9-CM, dislocation is listed as a nonessential modifier or one that is included in the fracture code.

One type of fracture that is not classified in the injury and poisoning codes is a pathological or spontaneous fracture. Codes 733.10-733.19 are used to identify pathological fractures and are chosen by the anatomical site of the fracture (the fifth digit). The term "compression" is sometimes used to refer to vertebral fractures and may be caused by disease or injury. Documentation of the etiology of this type of fracture is necessary to ascertain the correct code.

Codes for fracture management are located in the musculoskeletal section of the CPT book. These codes are global services and include the medical examination, open or closed treatment of the fracture, and normal, uncomplicated follow-up care. Any postoperative complications requiring additional procedures should be billed separately. Also, any subsequent cast applications and supplies are billed independently. When selecting a procedural code for fracture care, consider the following:

  1. The site of the fracture.
  2. Open vs. closed treatment.
  3. Manipulation performed.
  4. Skin or skeletal traction application.
  5. Percutaneous skeletal fixation application.

Fracture care is separated in CPT according to the difficulty of the physician's work. The type of fracture (e.g., communited, linear, missile) does not always have an impact on the type of treatment (e.g., open, closed) provided.

Percutaneous fixation, (e.g., codes 24538, 24582), may require the use of radiologic guidance. If this is the case, report code 76000 in addition to the procedure code. The physician should append a -26 to the end of the fluoroscopy code if the physician does not own the fluoroscopy equipment. Also, check with individual payers to verify reimbursement for the fluoroscopy code.

Bonnie Schreck, BS, CCS, CPC, CPC-H is a medical coding specialist for the American Academy of Professional Coders, Salt Lake City, Utah.

Coding courses

The Academy and KarenZupko & Associates, a Chicago-based medical marketing and management firm, will offer a half-day course, "Reducing Your Accounts Receivable for Profitable Orthopaedic Surgery Practices," followed by a one-day course, "1998 Coding and Reimbursement Update for Orthopaedic Surgery" Oct. 23-24 in Atlanta and Nov. 13-14 in Chicago. Separate registration is available. Contact KarenZupko at (312) 642-5616 or fax (312) 642-5571.

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