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.

General Documentation:

  • Anatomical Site, when applicable (bone, join or muscle involved)
  • Laterality (left, right, bilateral), when applicable

 ATC RAD ReveNews Oct

In summary, all fracture cases must include specific detail regarding pathologic versus traumatic.

2015 Draft ICD 10-CM Manual (AMA), ICD-10 Draft Official Guidelines for Coding and Reporting 2014, pages 15, 49, 67.

Author - Female

About the author

Myra Blankenship, CIRCC, CPC of Compliance-Radiology, McKesson Business Performance Services.