October 1st has passed and we now have a couple months of experience under our belt. What is evident is that clear and specific documentation is the key to improving communications between clinicians and coders. And it’s also important that the relationship between the anesthesia provider and the surgeon allows for good communication in order to obtain as much information as possible to document to the highest level of specificity.

During this time, we at McKesson have seen areas that still need improvement. Fractures is an area that requires documentation improvement. Accurate fracture reporting requires documentation of the type of fracture, specifically if “pathologic” versus “traumatic”. If this information is not included in the final dictated report, an ICD-10 code may not be reported and additional clinical detail will be required. This information will help determine the correct coding section.

Pathological fracture codes are found in Chapter 13 “Diseases of the Musculoskeletal System and Connective Tissue.” Per the guidelines, “[a] code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal healthy bone."1

  • Traumatic fracture codes are found in Chapter 19 Injury, Poisoning, and certain Other Consequence of External Causes.
  • A traumatic fracture may be caused by some type of accident, trip/fall, or other external force whether direct or indirect. Whereas a pathological fracture is due to disease that may cause a bone to break spontaneously without trauma.
  • Also keep in mind that the site of service is not supportive of traumatic vs. pathological
  • The provider will need to clearly document the fracture as traumatic or pathologic in order for an accurate ICD-10 code to be assigned. ICD-10 guidelines state I.C13.b “If it is difficult to determine from the documentation in the record which code is best to describe a condition, query the provider.”2

Diagnoses from Chapter 19, Injury, Poisoning and Certain Other Consequences of External Causes, require the documentation to have much greater specificity, most notably for fractures and burns. Note below as we recap required documentation for Fractures, Injuries, and Burns.

Required Documentation for Coding Fractures

  • Traumatic vs. Non Traumatic* (pathological)
  • Laterality (left or right)
  • Specific site of the facture (proximal, distal, and shaft)
  • Malunion or Nonunion
  • Routine vs. delayed healing
  • Displaced vs. non displaced
  • Type of encounter:
    A-Initial encounter: used while the patient is receiving active treatment for the conditions.3
    • Open vs. closed
    • Some open fracture codes allow for further classification based on the Gustilo open fracture classification (i.e., type I, II, IIIA, IIIB, IIIC)
    D- Subsequent encounter: used after the patient has received active treatment of the condition and is receiving routine care for ht the condition during the healing or recovery phase
    S- Sequela: used for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn
    *Per the guidelines for Chapter 19, “a code from category M80 and not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma would not usually break a normal, healthy bone.”4
  • In ICD-9, if the fracture was documented traumatic or pathological, per the guidelines, the coder was to assign the first listed. ICD-10 does not have this guideline. The provider will need to clearly document the fracture as traumatic or pathologic in order for an accurate ICD-10 code to be assigned. ICD-10 guidelines state I.C13.b “If it is difficult to determine from the documentation in the record which code is best to describe a condition, query the provider”.5

Required Documentation for Coding Injuries

  • Superficial injuries (Abrasions or Contusions) vs Lacerations.
  • Laterality
  • Anatomic site (joint specific)
    • Left, right, anterior, posterior, inferior, percentage displaced, medical and lateral
    • Type of encounter:
      A-Initial encounter
      D- Subsequent
      S- Sequela
  • Dislocations, Sprain of joints and ligaments, Tears – specifically, with meniscus injuries location and type are also required.
  • Traumatic vs. nontraumatic (old)
  • Location
  • Type
  • Laterality
  • Anatomic site (joint specific)
    • Left, right, anterior, posterior, inferior, percentage displaced, medial and lateral
  • Type of encounter:
    A-Initial encounter
    D- Subsequent
    S- Sequela

Required Documentation for Coding Burns

“There is a distinction between burns and corrosions. The burn codes are for thermal burns, (except sunburns), that come from a heat source, such as a “fire or hot appliance”.  The burn codes are also for burns resulting from electricity and radiation. Corrosions are burns “due to chemicals”.6
Burns are classified by depth, extent and by agent.

  • Depth: First degree: erythema
    Second degree: blistering
    Third degree: full – thickness involvement

Codes are assigned for each burn site (body region). Burns can be of different depths on different body surfaces. Additionally, burns are classified according to extent of body surface involved using the “rule of nines” for estimating body surface involvement:

  • Head and neck are assigned 9%
  • Each arm is 9%
  • Each leg is 18%
  • Both anterior and posterior are 18% each
  • Genitalia is 1%

Providers may change these percentage assignments where necessary to accommodate infants and children who have proportionately larger heads than adults, and patients who have large buttocks, thighs or abdomen that involve burns.

Of note, encounters for the treatment of the late effects of burns or corrosions (i.e. contractures of joints or scars) are coded with a 7th character “S” to identify sequelae.

As a reminder, documentation requirements that may not have been presented in the past are now requirements for ICD-10 coding. If your requests for additional information have been increasing, then the documentation may not be there for your coder to assign the appropriate code.

1 ICD-10 – CM, 2015 Complete Draft Code Set, Chapter 13. Diseases of the Musculoskeletal System and Connective Tissue, Page 19.
2 ICD-10 – CM, 2015 Complete Draft Code Set, Chapter 13, Diseases of the Musculoskeletal System and Connective Tissue, Page 14
3 ICD-10 – CM, 2015 Complete Draft Code Set, Chapter 19 - Injury, Poisoning, and Certain Other Consequences of External Causes, Page 19.
4 ICD-10 – CM, 2015 Complete Draft Code Set, Chapter 13 - Diseases of the Musculoskeletal System and Connective Tissue, Page 19.
5 ICD-10 – CM, 2015 Complete Draft Code Set, Chapter 13, Diseases of the Musculoskeletal System and Connective Tissue, Page 14
6 ICD-10 – CM, 2015 Complete Draft Code Set, Chapter 19, Injury, Poisoning, and Certain Other Consequences of External Causes, Page 19.

Author - Female

About the author

Mary Jo Gross, CPC, CANPC of Compliance – Anesthesia and Pain Management, McKesson Business Performance Services