Coders still need to read the operative report and code only what the physician actually performed. So coders would report code S62. For example, if a patient fractures his leg after falling off the roof while replacing the tiles, this is a clear example of a traumatic fracture. The codes are further divided by the specific finger fractured and whether the fracture is displaced or nondisplaced. This is also a low-energy injury.
If no multiple site code is available, report multiple codes. Type of fracture Providers must document, in some form, whether the fracture is traumatic or pathologic. Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. Site of fracture Coders must know the site of the fracture. An Excludes2 note indicates that the condition excluded is not part of the condition it is excluded from but a patient may have both conditions at the same time. One thing coders will need to look for is the episode of care.
Laterality and type of encounter initial, subsequent, sequela are significant components of the code expansion. A 42 year-old female restrained passenger was involved in a motor vehicle accident. When using seventh character S, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The sequencing for a toxic effect of substances chiefly nonmedicinal as to source T51-T65 is the same as for coding poisonings. Poisoning codes have an associated intent: accidental, intentional self-harm, assault, and undetermined. References National Center for Health Statistics.
An example of the sequencing for a poisoning is: Coma due to acetaminophen overdose suicide attempt T39. This includes identification of side, detailed location of the fracture in the bone, type of fracture, and description of healing. Sequela S is used for complications or conditions that arise as a direct result of an injury, such as scar formation after a burn. S32 Fracture of lumbar spine and pelvis S32. Coding of Traumatic Fractures The principles of multiple coding of injuries should be followed in coding fractures.
The Silver Lining For decades healthcare organizations have asked for more detail regarding fractures. Coding of Injuries When coding injuries, assign separate codes for each injury unless a combination code is provided, in which case the combination code is assigned. As a result, insufficient documentation of pathologic fractures can be problematic for coders, says Nicholson. If the force from a fall or trauma is insufficient to break a healthy bone, the fracture is pathologic, Nicholson says. The S is added only to the injury code, not the sequela code. The S seventh character identifies the injury responsible for the sequela.
Will often need further soft-tissue coverage procedure i. The sequencing for coding an adverse effect is the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug T36-T50. The Gustilo classification is used to identify the severity of the soft tissue damage. For complication codes, active treatment refers to treatment for the condition described by the code, even though it may be related to an earlier precipitating problem. When coding for the fracture, select the code based on the site of the fracture, not the location of the osteoporosis, Nicholson says. A type 1 Excludes note is a pure excludes. The injuries occurred in an automobile accident.
Coders should look for documentation of which part of the femur he fractured. Instead, report the code for the actual fracture, such as S52. For any documented infected burn site, coders should use an additional code for the infection. All these speakers were right. Codes for underdosing should never be assigned as principal or first-listed codes. Vague clinical documentation in orthopedic service lines will result in less revenue, foggy quality scores and poor follow-up care.
So how do coders tell the two types of fractures apart? While the classification defaults to displaced for fractures, it is very important that complete documentation is encouraged. In this case, coders would report a closed reduction with internal fixation instead of the open reduction. For example, a patient fractures his femur. Site of the fracture Coders will also need to know the site of the fracture, and that includes not just which bone is broken, but where on the bone the fracture is, Gold says. Sequela are complications from the original injury.
The seventh character identifies open fractures using the Gustilo-Anderson classifications, which are the most commonly used classifications for open fractures. The car left the highway at high-speed after hitting a pothole and suffering mechanical failure. A fracture not indicated whether displaced or nondisplaced should be coded to displaced. The mechanism often involves high-energy trauma, resulting in a severely unstable fracture with varying degrees of fragmentation. Additional terms found only in the may also be assigned to a code. If more than one site is involved, coders can report multiple site codes, says Nicholson.