CODING FRACTURES IN ICD-10

ICD-10 & Orthopedic Coding 

Documentation is the

 for specificity

• ·         Type of fracture (Open, closed, pathological, neoplastic disease, stress)
• ·         Pattern (Comminuted, oblique, segmental, spiral, transverse)
• ·         Etiology to document in the external cause codes
• ·         Encounter of care (Initial, subsequent, sequelae)
• ·         Healing status, if subsequent encounter (normal or delayed healing, nonunion, malunion)
• ·         Localization (Shaft, head, neck, distal, proximal, styloid)
• ·         Displacement (Displaced, non displaced)
• ·         Classification (Gustilo-Anderson, Salter-Harris)
• ·         Any complications, whether acute or delayed (Direct result of trauma sustained)
• ·         Intra-articular or extra-articular involvement ICD-10 Clinical Concepts  

Some Traumatic Fracture Coding Tips

A fracture not documented as open or closed should be coded to closed. 

A fracture not documented as displaced or not displaced should be coded to displaced.

Traumatic fractures are coded using the appropriate 7th character for initial encounter (A, B, C) while the patient is receiving active treatment for the fracture. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician. 

The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.

Fractures are coded using the appropriate 7th character for subsequent care for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase. Examples of fracture aftercare are: cast change or removal, removal of external or internal fixation device, medication adjustment, and follow-up visits following fracture treatment.

Care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes.

Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7th character for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R)

The aftercare Z codes would not be used for aftercare for traumatic fractures. For aftercare of a traumatic fracture, assign the acute fracture code with the appropriate 7th character. ICD-10-CM Official Guidelines for Coding and Reporting