Q. We treat a lot of fractures in our urgent care clinic, and I understand there are changes for coding these in ICD-10-CM [International Classification of Diseases, 10th Revision, Clinical Modification]. What will we need to be aware of?

A.Most of the changes made in ICD-10-CM were to chapter 19, “Injury, Poisoning, and Certain Other Consequences of External Causes (S00-T88),” because of the need to identify laterality and 7th-character extensions that indicate the type of encounter for the injury. Code descriptions include right and left designation, as well as bilateral designation when appropriate. There is also a designation for “unspecified,” but best practice would be to query the health-care provider for further documentation if laterality is not mentioned in the notes.
Most categories in chapter 19 have a 7th-character requirement for each applicable code. The majority of fracture codes will have encounter types:

  • A: Initial encounter
  • D: Subsequent encounter
  • G: Subsequent encounter for closed fracture with delayed healing
  • K: Subsequent encounter for closed fracture with nonunion
  • P: Subsequent encounter for closed fracture with malunion
  • S: Sequela

These are other choices for fracture encounters that you will find throughout the chapter:

  • B: Initial encounter for open fracture type I or II
  • C: Initial encounter for open fracture type IIIA, IIIB, or IIIC
  • E: Subsequent encounter for open fracture type I or II with routine healing
  • F: Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing
  • H: Subsequent encounter for open fracture type I or II with delayed healing
  • J: Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing
  • M: Subsequent encounter for open fracture type I or II with nonunion
  • N: Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion
  • Q: Subsequent encounter for open fracture type I or IIwith malunion
  • R: Subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

According to the guidelines, 7th character A (initial encounter) is used while the patient is receiving active treatment for the condition. Examples of active treatment in ICD-10-CM are the same as currently listed in ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification): surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.
True to their description, these 7th-character extensions must be located in the 7th position within the code. Therefore, there will be times that you will need to use an X placeholder in the 5th and/or 6th positions in order for the encounter type to appear in the 7th position. For example, the code selection for the fracture of a medial malleolus is only 5 digits:

  • S82.51: Displaced fracture of medial malleolus of right tibia
  • S82.52: Displaced fracture of medial malleolus of left tibia
  • S82.53: Displaced fracture of medial malleolus of unspecified tibia
  • S82.54: Nondisplaced fracture of medial malleolus of right tibia
  • S82.55: Nondisplaced fracture of medial malleolus of left tibia
  • S82.56: Nondisplaced fracture of medial malleolus of unspecified tibia

To bill a complete code, you must insert an X placeholder as the 6th digit so that the encounter can be placed in the 7th position. The complete code for a displaced fracture of the medial malleolus of the right tibia, initial encounter, is S82.51XA. The equivalent ICD-9-CM code is 824.2, “Fracture of medial malleolus, closed.”

Guidelines for coding aftercare have also changed in ICD-10-CM. Today, you would use aftercare codes from subcategories V54.0, V54.1, V54.8, or V54.9 to represent aftercare treatment. When you start using ICD-10-CM, you will code the acute injury code with the 7th digit D, “subsequent encounter” for most fractures, or one of the other appropriate subsequent-encounter codes mentioned earlier to represent routine or delayed healing, nonunion, or malunion. You would not use aftercare Z codes for injuries or poisonings, where the 7th characters are provided to identify subsequent care. For example, if your patient is returning for cast removal after a greenstick fracture of the right arm, you would code S523.311D, “greenstick fracture of shaft of radius, right arm, subsequent encounter for fracture with routine healing,” to report the diagnosis for the visit.

The last big coding change in chapter 19 has to do with late effects. Today, you search for the term late effect and look for the condition listed under the term. In ICD-10-CM, late effect has been removed and replaced by the term sequela. A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The condition or the nature of the sequela is sequenced first; then you will code to the injury with the 7th character S. For example, your patient returns to your clinic with a complaint of pain in her right wrist. Six months earlier, she was treated for a scaphoid fracture of the right wrist. Currently, you would bill 719.43, “pain in joint, forearm,” and 905.2, “late effect of fracture of upper extremities.” In ICD-10-CM, you will code M25.531, “pain in right wrist,” and S62.011S, “displaced fracture of distal pole of navicular [scaphoid] bone of right wrist, sequela.”

Note: CPT codes, descriptions, and other data only are © 2011, American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).

Disclaimer: JUCM and the author provide this information for educational purposes only. The reader should not make any application of this information without consulting with the particular payors in question and/or obtaining appropriate legal advice

DAVID STERN, MD (Practice Velocity)

Fractures in ICD-10-CM

David Stern, MD

Chief Executive Officer at Practice Velocity Urgent Care Solutions, Founding Member of the Urgent Care Association of America, Publishing Staff for The Journal of Urgent Care Medicine
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