Medical Coding News

Brigid T. Caffrey, BS, CCS, Clinical/Technical Editor

Coding of traumatic fractures in ICD-10-CM will be a particularly difficult adjustment for coders used to coding in ICD-9-CM. Not only are fractures listed differently in the ICD-10-CM alphabetic index, but they are identified according to some new classification systems.

The first notable change from ICD-9-CM to ICD-10-CM related to fracture coding is that the ICD-10-CM alphabetic index has two separate main entries for “Fracture”: one for pathological and one for traumatic fractures. Some of the terms used in ICD-10-CM to identify traumatic fractures encompass fracture characteristics and classification systems. Some terms will be familiar from ICD-9-CM, but others are new for ICD-10-CM. It is important to keep in mind that the increased specificity of ICD-10-CM requires that the user have a solid understanding of the terms relating to fractures, as well as the pathophysiology involved.

• Open/closed: According to ICD-10-CM Official Coding Guidelines section I.C.19.c, a fracture not identified as open or closed is coded as closed. In ICD-10-CM, fracture codes require a seventh character for the episode of care, some of which are based on whether the fracture is closed or open. This designation varies, so it is necessary to review the tabular table for the correct choices. Also note that some fractures, such as Torus, are only closed. New for ICD-10-CM is another indication for open fracture of an extremity, the Gustilo open fracture classification. This classification applies only to the following categories: S52 Fracture of forearm, S72 Fracture of femur and S82 Fracture of lower leg. The seventh-character extensions for these codes incorporate the classification. The classification has three categories that are defined by mechanism of injury or amount of energy (velocity), degree of bone injury, and extent of soft tissue damage and contamination; the third category is further subdivided into grades based on adequacy of soft tissue coverage and vascular injury.
• Closed: simple fracture in which the skin is intact or an open wound or puncture does not communicate with the fracture site
• Open: fracture involving wounds that communicate with the fracture site either by the bone breaking through the skin surface or by a wound penetrating down to the bone (i.e., bullet), exposing the fracture to contamination and  possible infection (osteomyelitis)
• Gustilo classification of open fracture of extremity:
• Type I: low-energy/velocity, clean wound, wound <1 cm in length, minimal soft tissue injury, minimal fracture comminution
• Type II: moderate contamination, wound >1 cm in length with moderate soft tissue damage (flaps, avulsion), minimal fracture comminution
• Type III: high-energy/velocity or crushing (i.e., injuries due to farm accidents, gunshot, war, tornado, high-speed vehicle), massive/highly contaminated wound, wound >1 cm in length, extensive soft tissue damage/loss (flaps, avulsion, crush) requires vascular repair or has been open for eight hours prior to treatment, segmental or severely comminuted fracture with displacement, bone loss, traumatic amputation
• Grade IIIA: Adequate soft tissue coverage, wound <10 cm 
• Grade IIIB: Inadequate soft tissue coverage, wound >10 cm in length 
• Grade IIIC: Associated major vascular (arterial) injury requiring repair for limb salvage
• Salter-Harris physeal fractures: Physeal, or growth-plate (epiphyseal plate or cartilage), fractures occur in the proximal or distal physis of long bones in children and adolescents. When such fractures occur, the cartilaginous tissue becomes disrupted or separated and may affect bone growth. The Salter-Harris classification system identifies the increasing severity of physeal fractures; although there are nine levels, ICD-10-CM uses only the first four, which are the most commonly seen. The long bone subcategories with the Salter-Harris classification are S49.0 Physeal fracture of upper end of humerus, S49.1 Physeal fracture of lower end of humerus, S59.0 Physeal fracture of lower end of ulna, S59.1 Physeal fracture of upper end of radius, S59.2 Physeal fracture of lower end of radius, S79.0 Physeal fracture of upper end of femur, S79.1 Physeal fracture of lower end of femur, S89.0 Physeal fracture of upper end of tibia, S89.1 Physeal fracture of lower end of tibia, S89.2 Physeal fracture of upper end of fibula, and S89.3 Physeal fracture of lower end of fibula. The Salter-Harris codes are located in the alphabetic index under “Fracture (specified long bone), (upper) or (lower) end, physeal, Salter-Harris Type (I, II, III, IV as appropriate).” The tabular list table for episode of care notes that physeal fractures are only closed.
• Type I: fracture through the growth plate separating the epiphysis from the diaphysis
• Type II: fracture through the growth plate and metaphysis or portion of the diaphysis (shaft) without a fracture of the epiphysis
• Type III: fracture through the growth plate and epiphysis with a complete break through the epiphysis, intra-articular; does not involve the metaphysis
• Type IV: fracture through the diaphysis (shaft), metaphysis, growth plate, and epiphysis
• Displaced/nondisplaced: The term “displaced” is a nonessential modifier in the alphabetic index; the term “nondisplaced” is an essential modifier. According to ICD-10-CM Official Coding Guidelines section I.C.19.c, a fracture not documented as to whether it is displaced or nondisplaced is coded as displaced. A nondisplaced fracture does not require manipulation or reduction; a facture may initially be nondisplaced but become displaced because the patient fails to keep weight off it or due to some other factor.
• Displaced: Bone ends are separated and lose anatomical alignment.
• Nondisplaced: Bone ends are separated but do not move and therefore maintain anatomical alignment.
• Subluxation/dislocation: The ICD-10-CM alphabetic index entry for “Dislocation, fracture” has a reference to “see Fracture.” Subluxation has no entry for “fracture” but states “see also Dislocation.” Therefore, for the majority of fracture sites, subluxation/dislocation of a joint is included in the code for the fracture. The subluxation/dislocation categories S13.1 Subluxation and dislocation of cervical vertebrae, S23.1 Subluxation and dislocation of thoracic vertebra, and S33.1 Subluxation and dislocation of lumbar vertebra, have an excludes2 (“not included here”) note for fracture of the vertebral locations, meaning that the specified fracture code is not included in the subluxation/dislocation code and it may be acceptable to code both when supported by the documentation.
• Subluxation: partial or incomplete separation (dislocation) of a joint with misalignment but maintenance of some contact between the bones
• Dislocation: the separation of the bone ends of a joint from their normal anatomical positions
• Sacral zone vertical fractures and transverse fracture types: The ICD-10-CM alphabetic index entry for “Fracture, sacrum” now has entries for the Denis classification, which is based on fracture anatomy of vertical sacral fractures, identified as zone I, zone II, or zone III for category S32.1 Fracture of sacrum. The index further indicates subcategories based on whether these fractures are nondisplaced or minimally or severely displaced. In addition, the index has entries for the subclassification identified as type 1 through type 4 by Roy-Camille and modified by Strange-Vognsen for a transverse fracture of the sacrum, which is an expanded zone III, often involving all three anatomical zones. The tabular note under category S32.1 instructs the user to code vertical fractures to the most medial extension and to assign two codes if both a vertical (zone) and a transverse (type) fracture are present.
• Vertical sacral fracture (Zone):
• Zone I: Anterior column with anterior longitudinal ligament and anterior half of vertebral body, lateral ala fracture with possible extension into the sacroiliac joint, lateral to the foramina, nondisplaced or minimally displaced, vertical shear are unstable, neurological deficits can occur involving L5 nerve root.
• Zone II: Middle column with posterior longitudinal ligament and posterior half of the vertebral body, transforaminal fracture but no spinal canal involvement, foramina can be patent; if foramina is compromised or unstable then surgery may be indicated; neurological deficits usually involving L5, S1, and S2 nerve roots (sciatica, occasional bladder dysfunction) may include the sacral ala.
• Zone III: Posterior column with supraspinous ligaments and pedicles and facet joints, central sacral canal fracture extends into the spinal canal and involves the spinal cord, highest severity of neurological deficits (saddle anesthesia, loss of sphincter control; cauda equina syndrome, and sexual dysfunction, can also include zones I and II.
• Transverse sacral fractures (type):
• Type 1: transverse flexion fracture without displacement, angulated but without significant deformity
• Type 2: transverse flexion fracture with posterior displacement, angulated and displaced
• Type 3: transverse extension fracture with anterior displacement, with neurological impingement, complete dislocation
• Type 4: transverse segmental comminution of upper sacrum, sacral burst fracture due to axial loading