November 24, 2008

Coding for Fractures
For The Record
Vol. 20 No. 24 P. 28

More than one third of adults aged 65 and older fall each year in the United States. Among older adults, falls are the leading cause of injury deaths and the most common cause of nonfatal injuries and hospital admissions for trauma. The rates of fall-related deaths among older adults rose significantly over the past decade.

ICD-9-CM Coding for Traumatic Fractures
Traumatic fractures are classified to ICD-9-CM categories 800 to 829. The three-digit category code identifies the bone involved, with the fifth digit specifying which part of the bone, if needed. The fourth digit identifies whether the fracture was open or closed. If the medical record does not provide specificity, the fracture is classified as closed. A closed fracture does not have an open wound associated with it. The following terms are descriptions of a closed fracture: comminuted, depressed, elevated, fissured, fracture NOS (not otherwise specified), greenstick, impacted, linear, simple, slipped epiphysis, and spiral.

An open fracture has an open wound associated with the fracture. The following terms describe an open fracture: compound, infected, missile, puncture, and with foreign body.
Coding of multiple fractures should follow the same guidelines as coding for multiple injuries.

ICD-9-CM Coding for Nontraumatic Fractures
A nontraumatic or pathological fracture is a break of a diseased or weakened bone without any identifiable trauma or following a minor injury that would not ordinarily break a healthy bone. A pathological fracture is classified to code 733.1x, with a fifth digit identifying the fracture site. Pathological fractures often occur in the vertebra (733.13), hip (733.14), and wrist (distal radius or Colles’ fracture, 733.12). Vertebral fractures most often occur in weight-bearing vertebrae (T-8 or below) and are treated with back braces, analgesics, and physical therapy. Hip fractures are commonly treated by partial or total hip replacement (81.52 or 81.51, respectively) or by open reduction internal fixation of the hip (79.35). Wrist fractures are placed in casts for six to 10 weeks or reset surgically. Fractures tend to heal slowly in patients with osteoporosis.

Underlying causes of pathological fractures include osteoporosis, metastatic bone tumor, osteomyelitis, Paget’s disease, disuse atrophy, hyperparathyroidism, and nutritional or congenital disorders. However, the fact that the patient has a bone-weakening condition does not mean the fracture is pathologic. Only the physician can determine whether the fracture is considered traumatic or pathologic, and physician documentation must be obtained to clarify the diagnosis.

The following terms are synonymous with pathological fracture: insufficiency fracture, spontaneous fracture, nontraumatic fracture, and nontraumatic compression fracture.

When one of these terms is documented in the medical record, code 733.1x with the appropriate fifth digit may be assigned instead of a code from 800 to 829. If the physician documents stress fracture, assign one of the following codes:

• 733.93, Stress fracture of tibia or fibula;

• 733.94, Stress fracture of the metatarsals;

• 733.95, Stress fracture of other bone;

• 733.96, Stress fracture of femoral neck;

• 733.97, Stress fracture of shaft of femur; and

• 733.98, Stress fracture of pelvis.

Compression Fractures
Compression fractures may be considered traumatic or pathologic. Review the medical record to determine whether there was significant trauma to cause the compression fracture. If the documentation is unclear, ask the physician for clarification. Never assign a code for a traumatic fracture with a code for a pathologic fracture at the same site. Common treatments of compression fractures include the following:

• Vertebroplasty (81.65) is performed on patients for the treatment of vertebral compression fractures. It involves injecting a semiliquid material (polymethyl methylacrylate or methyl methacrylate) into the vertebral body. The material hardens and, in turn, stabilizes and strengthens the compression fracture. This procedure helps decrease pain and increase mobility in patients with osteoporosis (AHA Coding Clinic for ICD-9-CM, 1999, fourth quarter, page 22).

• Kyphoplasty (81.66) is a technique that combines vertebroplasty with the insertion of an inflatable bone tamp that restores the vertebral body height while creating a cavity to be filled with bone cement.

Coding and sequencing for fractures are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.