For accurate ICD-10-CM and CPT coding of fracture treatments, medical coders should identify the following critical details from the physician’s documentation:
- Fracture Location and Laterality: Specify the anatomical location (e.g., distal, proximal, mid-shaft) and laterality (if applicable) of the fracture. Common anatomical terms include distal, middle, proximal, mid-shaft, apophyseal, articular, periarticular, and others.
- Traumatic vs. Non-Traumatic Fracture: Determine whether the fracture is caused by trauma or a pathological condition (e.g., osteoporosis). Traumatic fractures are coded with S codes from Chapter 19 of ICD-10-CM, while pathological fractures are coded with M codes from Chapter 13. If the cause is unclear, the ICD-10-CM index will provide a default code.
- Open vs. Closed Fracture: Identify if the fracture is open (with a wound) or closed. Open fractures carry a higher risk of infection and may require additional procedures like debridement, which are separate from fracture care itself.
- Displaced vs. Nondisplaced Fracture: A displaced fracture involves bone fragments that have separated, while a nondisplaced fracture means the bones remain aligned. Key phrases such as “20-degree angulation” may indicate displacement.
- Fracture Type: Common fracture types include avulsion, chip, greenstick, hairline, oblique, and comminuted, among others. Ensure accurate documentation of the fracture’s characteristics.
- Treatment Method: Verify whether the treatment was open, closed, or percutaneous:
- Open treatment involves surgical incision and alignment of bone fragments, often with internal or external fixation.
- Closed treatment typically involves casting or bracing without surgery.
- Percutaneous treatment uses pins or other devices, often under X-ray guidance.
- Manipulation: If the fracture required manipulation (realignment), document whether it was performed. The term “reduction” is used interchangeably with “manipulation” and typically refers to the procedure of aligning the fracture.
- Internal Fixation: Confirm if internal fixation (e.g., screws, plates) was used during the procedure, and ensure it is reflected in the fracture treatment code. Check if the code specifically requires internal fixation or states “if performed.”
- External Fixation: Determine if external fixation was used, where pins are placed through the bone above and below the fracture site.
- Traction: Identify whether traction was applied and the type (skin or skeletal). Skin traction applies force through devices on the skin, while skeletal traction uses pins, screws, or wires inserted into the bone.
- Additional Procedures: Look for other procedures such as grafting, soft tissue repair, or skeletal fixation that may require separate coding.
- Anesthesia Type: Some fracture treatments may only be reportable if general anesthesia was used. Verify the type of anesthesia documented.
Fracture Global Period: What Can and Cannot Be Billed Separately
Medicare generally assigns a 90-day global period to most fracture treatment codes, including closed fractures with or without manipulation. The global package typically covers:
- Evaluation of the fracture on the same day as the treatment.
- Fracture reduction procedures (e.g., percutaneous pinning or open/closed treatment).
- Application and removal of the first cast or splint during the treatment encounter.
- Routine follow-up care visits, as long as there are no complications requiring additional procedures.
However, the following services are excluded from the global period and may be billed separately:
- Debridement of open fractures, including removal of foreign material.
- Follow-up imaging to assess fracture healing.
- Casting supplies for office-based cast application (use appropriate HCPCS Q codes).
- Complications requiring a return to the operating room.
- Subsequent cast replacements when necessary.
Ensure that these exclusions are properly documented and billed separately as required.