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Documentation and Coding:FracturesMay 2022At Healthfirst, we are committed to helping providers accurately document and code their patients’health records. Proper ICD-10 coding can provide a comprehensive view of a patient’s overall health.Coding of fractures can be challenging when selecting a 7th character on the ICD-10-CM code, andthis tip sheet will offer guidance on how to submit diagnosis code with greater specificity for fracturecoding. However, this document does not represent or guarantee that Healthfirst will cover and/or pay for services outlined. Coverage decisions are based on the terms of the applicable evidenceof coverage and the provider’s participation agreement. This includes the determination of anyamounts that Healthfirst or the member owes the provider.There are two types of fractures: traumatic and non-traumatic (pathological).To code fractures, identify the following:Traumatic ornon-traumatic fractureSite, laterality, and specificbones fracturedAssociated injuries(i.e., nerves, spinal cord injuries)Type of Encounter:Initial, Subsequent, or Sequela
Documentation and Coding:FracturesTraumatic Fracture Diagnoses CodesICD-10-CMDescriptionS02*Skull and facial bonesS12*Cervical vertebra and other parts of the neckS22*Ribs, sternum, and thoracic spineS32*Lumbar spine and pelvisS42*Shoulder and upper armS49*Other injuries of shoulder/upper armS52*ForearmS59*Other injuries of elbow and forearmS62*Wrist and handS72*FemurS79*Other injuries of hip and thighS82*Lower leg including ankleS89*Other injuries of lower legS92*Foot and toe, not including ankleS99*Other injuries of ankle and foot*Requires an additional digit to complete the diagnosis code
Documentation and Coding:FracturesTraumatic Fracture – Identifying an Initial or Subsequent EncounterSurgical TreatmentInitialEncounterClosed TreatmentED/EREvaluation andTreatment by NewPhysician(Not in Healing Stage)Cast Change orRemovalHealing or RecoveryPhase (i.e., PT/OT)SubsequentEncounterOther AftercareFollow-upRemoval of External orInternal Fixation DeviceMedicalAdjustment
Documentation and Coding:FracturesNon-Traumatic (Pathological) Fracture Diagnoses CodesP athological fracture in neoplastic disease should be sequenced first, followed by thecode for the neoplasm.I f the treatment is the neoplasm with an associated pathological fracture, the neoplasmcode should be sequenced first, followed by a code for the pathological fracture.M80.0* - M80.08*Age-related osteoporosis withcurrent pathological fractureM80.8A* - M80.8AX*Other osteoporosis with currentpathological fractureM84.3* - M84.38X*Stress fractureM84.40* - M84.9Pathological fracture*Requires an additional digit to complete the diagnosis codeNon-Traumatic Fracture - Identifying an Initial or Subsequent EncounterFractures in patients with known osteoporosis whose injury would not usually break a normal,healthy bone should not be classified with a traumatic injury code, but with a combination codefrom category M80 Osteoporosis with current pathological fracture.Initial Encounter (A)Subsequent Encounter (D)As long as the patient is receivingactive treatment for the pathologicfracture. 7th character is based onwhether the patient is undergoingactive treatment and not whetherthe provider is seeing the patientfor the first time.After the patient has completedactive treatment for the pathologicfracture and is receiving routinecare for the fracture during thehealing or recovery phase.
Documentation and Coding:FracturesDocumentation should also includeFractureDiagnosticToolsTraumatic Nontraumatici .e., X-rays,MRI ate andDcauseComplicationsTreatment Plan(If Any) i.e.,Infections,Thrombosis,Cancer, etc. Prognosis Othercomorbidities Indicate if patient is in the healing stage Historyof nontraumatic Medications Referrals for PT/OTI ndicate if pathological fracture is dueto other cause (i.e., Chronic steroid use,Vitamin deficiency, etc.)Coding Tips:M ultiple fractures are sequenced in accordance with the severity of the fractureD isplaced or nondisplaced - when not specified, the default is displacedO pen or closed fracture - when not specified, the default is closedO pen fractures of forearm, femur, and the lower leg including the ankle use theGustilo classificationType I or type IIType IIIA, IIIB, or IIICWhen the type is not specified, the default is type I or type II Healing stage includes the following key terms:Routine healingDelayed healingMalunionNonunion P rosthesis or presence of orthopedic joint implants Z96.6**Requires an additional digit to complete the diagnosis code
Documentation and Coding:FracturesThe 7th character indicates if the patient is receiving initial or subsequent treatment.Closed Fracture7thDescriptionCharacterAInitial encounter for fractureDSubsequent encounter for fracture with routine healingGSubsequent encounter for fracture with delayed healingKSubsequent encounter for fracture with nonunionPSubsequent encounter for fracture with malunionSSequelaOpen Fracture7thDescriptionCharacterBInitial encounter for open fracture type I or IICInitial encounter for open fracture type IIIA, IIIB, or IIICESubsequent encounter for open fracture type I or II with routine healingSubsequent encounter for open fracture type IIIA, IIIB, or IIIC withFroutine healingSubsequent encounter for open fracture - fracture type I or II withHdelayed healingSubsequent encounter for open fracture type IIIA, IIIB, or IIIC withJdelayed healingMSubsequent encounter for open fracture type I or II with nonunionNSubsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunionQSubsequent encounter for open fracture type I or II with malunionRSubsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunionTraumatic History CodeICD-10-CMZ87.81DescriptionPersonal history of (healed) traumatic fractureNon-Traumatic History sonal history of (healed) osteoporosis fracturePersonal history of (healed) other pathological fracturePersonal history of (healed) stress fracture
Documentation and Coding:FracturesCase 1A patient is admitted for surgical treatment of fracturemalunion involving the right mandibular condyle andmandibular symphysis. He had previously undergone openreduction with internal fixation. Category S02, Fracture ofskull and facial bones, does not provide a 7th character todescribe subsequent encounter for fracture malunion. Whatis the appropriate code assignment and 7th character for asubsequent encounter due to malunion of mandibular fracture?RationaleAssign codes S02.66XK, Fracture of symphysis of mandible,subsequent encounter for fracture with nonunion, and S02.611K,Fracture of condylar process of right mandible, subsequentencounter for fracture with nonunion, for the malunion of themandibular symphysis and right mandibular condyle fractures.Since there is no specific 7th character extension describingmalunion in category S02, assign “K” (nonunion) as the bestavailable option.Source: AHA Coding Clinic (Volume 8, First Quarter, 2021)Case 2The patient is an 89-year-old female with known osteoporosiswho fell from bed at the nursing home with resultant ribfractures. The provider was queried and confirmed that the ribfractures were due to osteoporosis due to her advanced age.How is this coded?RationaleAssign code M80.0AXA, Age-related osteoporosis with currentpathological fracture, other site, initial encounter for fracture,as the principal diagnosis. In addition, assign codes W06.XXXA, fall from bed, initial encounter, and Y92.122, Bedroom innursing home, as the place of occurrence of the external cause,to identify the external cause of injury and the location of thepatient at the time of injury.Source: AHA Coding Clinic (Volume 7, Fourth Quarter, 2020)Questions?Contact us at #Risk Adjustments and clinical Documentation@healthfirst.org.For additional documentation and coding guidance, please visit the Coding section at hfproviders.org.References: cmhttps://bok.ahima.org/PdfView?oid 107013https://www.codingclinicadvisor.comCoverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance Company, Inc. (together, “Healthfirst”). 2021 HF Management Services, LLC1701-21 XP22 117
(Not in Healing Stage) Other Aftercare Follow-up Medical Adjustment Closed Treatment Healing or Recovery Phase (i.e., PT/OT) ED/ER Removal of External or . Assign codes S02.66XK, Fracture of symphysis of mandible, subsequent encounter for fracture with nonunion, and S02.611K, Fracture of condylar process of right mandible, subsequent .
