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.
Information must be included to determine if the exam is being performed for follow-up or aftercare (i.e., evaluation of healing fracture). The applicable fracture code will be reported with the appropriate 7th character which communicates active care versus aftercare or follow-up. It is no longer enough to know the exam is for aftercare of a healing fracture, we must know if the fracture was traumatic versus pathologic.
- Anatomical Site, when applicable (bone, join or muscle involved)
- Laterality (left, right, bilateral), when applicable
In summary, all fracture cases must include specific detail regarding pathologic versus traumatic.