ICD-10-CM turned coding on its head when implemented in October 2015. The coding convention was so unlike the mostly numeric, five-character codes we were accustomed to in ICD-9. Now I wonder how we ever got along without the coding upgrade! If anything, the number of potential codes is staggering, which can lead to errors if providers and coders don’t fully read and apply coding guidelines. One area where we see mistakes is in orthopedic coding.
To clarify, the majority of our clients are primary care providers who operate under risk adjusted payment paradigms. Their ortho coding is mostly limited to back pain (and its more specific causation), arthritis and the occasional fracture. Most ortho codes seen in primary care do not risk adjust, but some fractures do, such as pelvic and hip breaks. We thought it prudent to review the seventh character in ortho ICD-10 codes to dispel any myths.
Here is the list of seventh characters for fracture of the femur, which coding guidelines say should be added to all codes from category S72:
- A – initial encounter for closed fracture
- B – initial encounter for open fracture type I or II, initial encounter for open fracture NOS
- C – initial encounter for open fracture type IIIA, IIIB, or IIIC
- D – subsequent encounter for closed fracture with routine healing
- 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
- G – subsequent encounter for closed fracture with delayed 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
- K – subsequent encounter for closed fracture with nonunion
- 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
- P – subsequent encounter for closed fracture with malunion
- Q – subsequent encounter for open fracture type I or II with malunion
- R – subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion
- S – sequela
The most important for our conversation is the initial encounter. We can all agree that a patient with a hip fracture is not generally seen in an outpatient setting for the initial encounter. He or she is seen in follow up after the fracture is surgically repaired by whatever means. The initial encounter character relates to the initial encounter for the condition, not the provider. This means that the initial encounter occurs in an emergency room, for the most part. Yet time and again, we see PCPs coding initial encounters for these fractures because it’s the first time the PCP is seeing the patient for the condition. Incorrect.
Moreover, only the initial encounter codes are risk adjusted, which means that PCPs who report this code during their visits are inflating their coding under the CMS-HCC model. And finally, notice the wording: “for ___ fracture.” Remember that providers report diagnoses they actually assess at the visit. Is the PCP seeing the patient for a fracture? Doubtful. Coding a condition whose care is deferred to another provider, in this case the orthopedist, is not proper because the PCP isn’t treating it. Using the M-E-A-T acronym as our documentation standard, the PCP can and should assess at the visit any other aspects of the fracture that persist beyond the initial encounter, such as pain, immobility, etc. By that point, the fracture – to use some coding humor – is history. Literally. (Z87.81)