How to Conquer the Challenges of Teaching Fracture Medical Coding

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As the aging population in America continues to grow, the need for health care and professional medical coders will continue to increase significantly. The scope and complexity of the transition to ICD-10-CM/PCS by healthcare providers in the United States is significant. The conversion to a modified version of the classification system already in use by the rest of the world will be a transformational effort in the U.S. affecting many systems, processes, and people. It will have a tremendous and widespread impact on every operational process across healthcare. Employers desire a well-trained workforce to ensure accuracy and to maximize revenue. ICD-10 CM/PCS implementation is generating a flurry of excitement in conjunction with an overall uneasiness about how prepare and adapt to the new system. This post is the third in a series from industry expert and award-winning author, Lorraine Papazian-Boyce, on some of the most complex medical specialties. To learn more from Lorraine Papazian-Boyce, sign up for one of her upcoming webinars here!

Coding of traumatic fractures is challenging because of the need for detailed anatomic specificity, the use of the ICD-10-CM seventh character to identify episode of care, and the frequent use of external cause codes. The task of instructors is multiplied when all codes sets—ICD-10-CM, ICD-10-PCS, ICD-9-CM, and CPT— are considered. There is little overlap among the coding guidelines and the guidelines are sometimes opposite for various code sets.

Challenges in diagnostic coding (ICD-10-CM, ICD-9-CM) include:

  • Distinguishing between traumatic and pathologic fractures.
  • Assigning the ICD-10-CM seventh character for episode of care and type of fracture.
  • Identifying laterality in ICD-10-CM, which is not documented consistently.
  • Assigning external cause codes for intent/event, place of occurrence, activity, and work status.

Challenges in procedure coding include:

  • Distinguishing between an open or closed fracture and open or closed treatment.
  • Identifying when to code casting or splinting.
  • Classifying the various types of fixation devices.

Accurate fracture coding requires a consistent, methodical approach, which I develop, using the three skills of an “Ace coder”: abstracting, assigning, and arranging (sequencing) codes. When abstracting, students review the medical record with a list of questions specific to fracture diagnoses and procedures. They must answer these questions before they begin coding the case. Examples of abstracting questions when coding ICD-10-CM are:

  • Where on the bone is the fracture located?
  • What is the Gustilo classification type for open fractures?
  • Is the encounter active treatment, follow-up during healing, or late effect?
  • What event caused the fracture?

CPT abstracting for fractures and dislocations requires that coders take note of the types of reduction, stabilization, fixation, and traction provided. Examples are:

  • What type of reduction is provided (open or closed)?
  • What general type of stabilization is provided (fixation or immobilization)?
  • Is restorative treatment provided by the individual who applied the cast or strapping?

ICD-10-PCS abstracting focuses on identifying the correct root operation. Examples are:

  • How many sites are treated?
  • Did the procedure put in, put back, or move some or all of a body part?
  • Does the procedure limit or prevent the movement of a body region?

Assigning codes involves using the Index and Tabular List to identify the code(s) for each condition or procedure, assigning all characters of the code, and following official guidelines and instructional notes in the coding manual. Diagnosis coding for traumatic fractures involves choosing from as many as 15 seventh-characters, based on the type or fracture, phase of healing, and whether or not a normal union has occurred during healing. When assigning CPT codes for restorative fracture care, it is best use the anatomic site as the main term in the Index; however, when coding for casting, use the main term Cast. The CPT Tabular List provides special instructions regarding when cast application and strapping should be coded separately from the E/M code and/or restorative treatment. When assigning ICD-10-PCS codes for certain immobilization and traction procedures, different PCS sections and, thus, different codes are applicable to hospital inpatient and rehabilitation settings.

Arranging (sequencing) codes involves again following official guidelines and instructional notes to place the codes in the correct sequence. ICD-10-CM Official Guidelines for Coding and Reporting provide guidance regarding sequencing of multiple fractures based on the severity of the fracture. When multiple inpatient procedures are performed, ICD-10-PCS requires sequencing the procedure most related to the principal diagnosis as the principal procedure, regardless of the price of the procedures or the order in which they were performed.

To help you better understand how to apply these principles to fracture coding, Pearson is hosting a free webinar Teaching Fractures Across Code Sets: ICD-9-CM, ICD-10-CM, ICD-10-PCS, CPT on Friday, October 30, 2015 1:00 PM – 2:30 PM Eastern Time. We will take a sample fracture case and code it in all code sets: ICD-10-CM/PCS, ICD-9-CM, and CPT. AHIMA and AAPC CEUs are offered. Click here to register. Registration is required and free.

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About the Author
Lorraine M. Papazian-Boyce, MS, CPC

Lorraine M. Papazian-Boyce, MS, CPC

Lorraine M. Papazian-Boyce is an award-winning author and instructor. She has authored two Pearson titles, ICD-10-CM/PCS Coding: A Map for Success, which received the Most Promising New Textbook Award–2013 from the Textbook and Academic Authors Association. Her newest title, Pearson’s Comprehensive Medical Coding is receiving rave reviews–students and instructors alike value her approach and simplified methodology of abstracting, assigning, and arranging code sets. She was named Educator of the Year – Instruction – 2011 by Career Education Corporation (CEC). Lorraine also contributed to the development of Pearson’s online, comprehensive coding solution, MyHealthProfessionsLab for Medical Billing & Coding. This new solution can be used across your entire coding program and covers content from all code sets.

Lorraine has taught at several career colleges, both traditional and online. She has over 30 years of experience in healthcare administration as office manager; biller and coder; management consultant to hospitals, nursing homes, and physicians; and former owner of a medical billing and coding service. Lorraine has contributed to numerous textbooks and journals in the health professions field and is a nationally-known speaker. She holds a M.S. in Health Systems Management; the CPC credential; and is an AHIMA-Approved ICD-10-CM/PCS Trainer and Ambassador.