Coding corner update: Improve medical record documentation for fractures and osteoporosis

Beginning Oct. 1, 2015, the transition to ICD-10-CM will affect every area of health care. Many codes contain much greater specificity. In the next several issues of The Record, you’ll find a series of revised “Coding corner” articles that include updated codes to align with the transition to ICD-10-CM.

Coding 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 treatment other 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. There were many new features added to the coding of fractures in ICD-10-CM. Fracture codes now include anatomical site, laterality and the addition of a required seventh character that describes the encounter or other information regarding the fracture. This article will explain these new features.

Documentation and coding tips for traumatic fractures
Codes for traumatic fracture are located in Chapter 19. The codes are grouped by body part or anatomical location rather than type of injury, so that fracture codes are located throughout the chapter. The first three characters of the ICD-10-CM fracture codes identify the bones involved, while the next three characters provide more specific information regarding location and type of fracture. If a code isn’t a full six characters in length, a place-holder “X” must be used to fill in the empty characters when a seventh character extension is required.

In ICD-10-CM a seventh character is required to identify additional information such as whether this is the initial or subsequent encounter, open or closed fracture, type of healing or other information.

Because the seventh character values for fractures can be significantly different it’s important to review the Tabular List at each category level to determine the appropriate value. Review the information on coding fractures in the ICD-10-CM official guidelines in Section 1.C.19.c. It’s important to note that a fracture diagnosis is invalid if it hasn’t been coded to the full number of seven characters 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 list the most serious fracture first, as determined by the attending physician. If the note isn’t clear, please don’t assume and assign an incorrect code, instead ask the physician.

Pathologic fractures
Pathologic fractures are assigned codes from ICD-10-CM categories and subcategories M80 and M84.4 through M84.6 according to the underlying cause. These codes are used for reporting both the active treatment of the fracture and for routine care for the condition during the healing or recovery phase. In ICD-10-CM, there are code categories for pathological fractures in neoplastic disease, other diseases, diseases not elsewhere classified as well as in osteoporosis.

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-10-CM Official Guidelines in Section 1.C.13.c. It’s important to note that just because the patient has a bone weakening disease doesn’t 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
In ICD-10-CM, for aftercare of a fracture, assign the acute fracture code with the seventh character identifying “subsequent encounter” with additional information such as routine or specified healing issues including delayed healing, malunion or non-union.

“Subsequent encounter” is used after the patient has received active treatment of the condition, during the healing or recovery phase. For proper selection of the seventh character for subsequent encounter it’s important to review the Tabular List at each category level to determine the appropriate value.

Examples of subsequent fracture care include:

• Change or removal of cast
• Removal of external or internal fixation device
• Medication adjustment
• An X-ray to check the healing status of the fracture

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 from categories M80 and M81, depending on whether there’s a current pathological fracture present. Review the ICD-10-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 has 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 acceptable when a definitive diagnosis hasn’t been confirmed by the health care provider in the outpatient setting.

Looking ahead to ICD-10-CM
The transition to ICD-10-CM will be easier if there’s a greater understanding of the guidelines, including changes to fracture coding.

Here’s an example of proper coding for a closed and open traumatic fracture of the left wrist:

ICD-10-CM coding for all conditions should follow coding conventions, chapter specific guidelines and general coding guidelines.

If you have questions or need more information, contact your provider consultant.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.