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June 2013
Follow these coding tips to improve medical record documentation for fractures, osteoporosis
About ICD-9-CM
ICD-9-CM is the national coding language used to translate a patient’s clinical condition into three- to five-digit codes. When reporting ICD-9-CM and current procedural terminology codes on claims, it’s critical that they’re supported by proper documentation in a patient’s medical record. Accurate coding starts with correct documentation
Coding for fractures can be a challenge considering the different types of fractures and certain bone diseases that can impact a fracture. These conditions can vary from serious (requiring immediate treatment) to chronic conditions that may call for other treatment rather than just a cast or strapping procedure.
In this article, you’ll find coding tips for traumatic and pathologic fractures (including aftercare for both) and osteoporosis, the most common bone disease.
Documentation and coding tips for traumatic fractures
Traumatic fractures are classified using ICD-9-CM categories 800 to 829. The three digits identify the bone involved, while a fourth digit indicates whether the fracture was open or closed and a fifth digit distinguishes the part of the bone affected. Review the information on coding fractures in the ICD-9-CM official guidelines in Section 1.C.17.b. A diagnosis is invalid if it has not been coded to the full number of digits required for that code.
Common fracture terms
- Closed fracture: Commonly used terms may include simple, comminuted, depressed, elevated, fissured, greenstick, impacted, linear, slipped epiphysis or spiral.
- Open fracture: Terms may include compound, infected, puncture or “with foreign body.”
To code multiple fractures, make sure the specific sites are coded individually and first list the most serious fracture, as determined by the attending physician. If the note is not clear, please don’t assume and assign an incorrect code; ask the physician.
Pathologic fractures are assigned codes from ICD-9-CM733.10-733.19. These codes are used for acute or a newly diagnosed pathologic fracture, and while the patient is receiving active treatment for it. Unlike fractures of normal bone, pathologic fractures occur during normal activity or from minor trauma due to weakening of the bone by disease, such as osteoporosis, neoplasms and osteomalacia.
Review the information on coding pathologic fractures in the ICD-9-CM Official Guidelines in Section 1.C.13.a. It’s important to note that just because the patient has a bone weakening disease does not mean a fracture is pathologic. Only the physician can determine whether the fracture is traumatic or pathologic.
Terms synonymous with pathological fractures may include spontaneous fracture, non-traumatic compression,
non-traumatic fracture or insufficiency fracture.
Coding for fracture aftercare
Aftercare codes for fractures are found in the supplementary classification V codes, located at the end of the tabular list.
- The range for traumatic fracture aftercare is V54.10-V54.19.
- The range for pathologic fracture aftercare is V54.20-V54.29.
The fourth digit distinguishes between traumatic and pathologic, and the fifth digit specifies the fracture site being treated. These codes are not assigned when treatment is directed at a current acute injury, but after active treatment of the fracture is completed and for routine care of the fracture during the recovery phase.
Examples of fracture aftercare include:
- Change or removal of cast
- Removal of external or internal fixation device
- Medication adjustment
Proper coding for osteoporosis
Osteoporosis is the most common bone disease. It’s an abnormal loss of bone tissue that results in fragile or porous bones. It typically has no symptoms until a fracture occurs, usually in the wrist, hip or vertebra. The code selection for osteoporosis is 733.00-733.09. Review the ICD-9-CM manual for the appropriate code selection.
Coding tip when term ‘rule out’ used
A challenge in the outpatient setting occurs when the term “rule out” is used. For example, a patient presents with swelling and pain in the wrist and is sent to a radiologist to rule outa fracture. It would be inappropriate to code a fracture until the condition is confirmed by the radiology report and the attending physician makes the determination. The physician also can determine whether the fracture is traumatic or pathologic. Coding signs and symptoms is only acceptable when a definitive diagnosis has not been confirmed by the health care provider in the outpatient setting.
For more information, please contact your provider consultant.
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