Open vs. Closed Fractures: Cut the Coding Confusion

For example, Carrie Arsenault, ART, CPC, a coding consultant with Health Information Services at Eastern Maine Medical Center, in Bangor, ME, sent chart notes for two tricky coding cases, requesting our comments.

Example 1: Fracture or Repair Treatment?

The patient caught his foot in the bedsheets, striking it on the frame of the bed. The result, according to the operative note, was a significant laceration over the dorsum of the right great toe with the distal phalanx quite floppy. Some bony structure emanated from the side of the laceration. The extensor tendon was completely avulsed from the distal phalanx.

The operative note states that an x-ray revealed a comminuted bilateral fracture of the proximal end of the distal phalanx. On further examination, the physician was able to look into the joint. He removed a couple of bone chips that were pretty much on the surface and not attached to anything. (No anesthesia was used because the patient had no sensation in the foot from a previous surgery.) The laceration was closed using six sutures and the toe was dressed snugly with gauze, incorporating the second toe as a splint.

All sources agree the fracture type in this case should be coded as 826.1 (open fracture of one or more phalanxes of foot). By definition, this fracture type was open, because the outside wound communicates with the fractured bone. The size of the soft- tissue wound is immaterial. The words appears to be bony structure in the operative notes alone indicates this is an open fracture. However, our sources for this article did not agree on whether the fracture treatment should be coded as open or closed.

Editors Note: Your coding choice will depend on the specifics of your particular fracture case, as well as whether you prefer to take a more conservative approach to coding.

One authority recommended 28505 (open treatment of fracture great toe, phalanx or phalanges, with or without internal or external fixation). She argued that even though the scenario did not match the CPTs definition of open treatmentfor example, the physician did not make an incision and work through that opening to repair the bonethe physician did work through the laceration to remove bone chips. Hence, the treatment was open.

Another expert suggested code 28490 (closed treatment of fracture great toe, without manipulation).

And yet other sources suggested simple repair codes in lieu of open-fracture treatment codes. Use 12001 (simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities, including hands and feet) if laceration is less than 2.5 cm and 12002 if it is from 2.6 to 7.5 cm.

Note: The fracture type does not have any coding correlation with the fracture treatment.

Example 2: Fracture or Wound Diagnosis?

The patient in this scenario, an elderly female, fell directly on her right kneecap, sustaining a laceration that grew progressively more painful after several hours. Over the patella, she had puncture wounds as well as tenderness and bony instability. An x-ray showed a patellar fracture. Under local anesthesia, the wound was irrigated, one small bone chip removed, and the wound repaired with three sutures. The orthopedist also used a Bacitracin dressing, a Jones dressing and knee immobilizer.

Coding sources did not agree on the diagnosis code. Some considered it open; hence, 822.1 (open fracture of patella). Others did not see enough evidence in the documentation to label it open; therefore, they recommended 822.0 (closed fracture of patella). A fall could cause an open wound, but does not necessarily result in an open fracture (see box at the end of this article for definitions).

However, they did agree that, in this case, the fracture treatment was not an open one because there was no internal fixation or patellectomy. Therefore, you would not use 27524 (open treatment of patellar fracture, with internal fixation and/or partial or complete patellectomy and soft tissue repair). (Although you could put a reduced-service modifier on code 27524 to possibly make it work, the sources agreed this scenario was not optimal.)

here was also no incision. Although the physician did remove one small bone chip, he or she did not make an incision to do so. You cant use an open code because there just wasnt enough work involved. Code 27372 (removal foreign body) would not be appropriate either. There is a loose body removed but not a foreign body. Since there was no incision, Im not inclined to use this code, says Dawn Carpenter, CPC, billing manager for Ortho Associates of Grand Rapids, MI.

The rationale for the closed treatment code is twofold. First, this code is appropriate when there is 2.0 mm or less displacement, separation, or step off. Second, closed treatment includes placing the leg in the initial long leg cast or splint to keep the knee immobilized for three to six weeks. The operative note indicated the fracture treatment consisted of only immobilization, which agrees with code 27520 (closed treatment of patella fracture without manipulation).

Instead of appending modifier -22, another option would be to code also for the laceration repair (12001-12021).

Note: The fact that the physician removed a bone chip through the laceration probably means an open fracture, says M. Bradford Henley, MD, MBA, associate professor of orthopedic surgery at Harborview Medical Center at the University of Washington in Seattle. In this case, a code from the debridement range (11010-11044) likely applies. If the fracture is non-displaced, then I agree with the fracture treatment code of 27520, he adds. (Be careful with a debridement code, because the operative note in this particular case did not indicate debridement.)

Editors Note: Coding advice was provided by Christine Banks, RRA, CPC, orthopedic coding specialist, Massachusetts General Hospital, Boston, MA; Susan Stradley, CPC, CCS-P, senior consultant for the Medical Group of Elliott, Davis and Co., LLP, headquartered in Greenville, SC. Along with the ICD-9-CM and CPT manuals, other references include Orthopaedics, Frank V. Alusio, MD, Christian P. Christensen, MD, and James R. Urbaniak, MD (Williams & Wilkins, 1990); AAOS Bulletin, January 1997.

Fracture Type and Treatment Affect Coding

In order to properly code for fractures" you have to understand the difference between a fracture treatment (designated by a CPT code ) and a fracture type (designated by a diagnostic code).

Fracture Type

One way in which fractures are classified is by the pattern of the fracture fragments such as simple or comminuted extra-articular or intra-articular. These patterns may be either closed or open.

Closed fracture: One in which the skin is intact overlying the fracture and its hematoma. Unless specified as open or compound a closed fracture according to the ICD-9-CM manual includes these descriptions: comminuted depressed elevated fissured greenstick impacted linear march simple slipped ephiphyis spiral unspecified.

Open fracture: One in which there is a break in the skin that communicates with the fracture site or the fracture site hematoma. For example an external force may break the bone which then exits through the skin. An open fracture can also occur when the fracture or dislocation is caused by blunt or penetrating force sufficient to disrupt or penetrate the skin subcutaneous tissue muscle fascia muscle and/or the bone or joint explains M. Bradford Henley MD MBA associate professor of orthopedic surgery at the University of Washingtons Harborview Medical Center in Seattle. Such fractures may be contaminated by foreign material such as clothing grass dirt gravel. They may also contain bacteria as well as dead or devitalized tissue which need to be removed to prevent infection and healing complications. The ICD-9-CM includes these descriptions for open fractures: compound infected missile puncture with foreign body.

Note: The term compound fracture has been synonymous with open fracture; however use of the former term is outdated.

Fracture Treatment

Fractures may be treated by either open or closed reduction methods. (A third fracture treatment percutaneous skeletal fixation will be examined in a later article.)

Closed treatment: The CPT manual states closed treatment specifically means that the fracture site is not surgically opened (exposed to the external environment and directly visualized.) This terminology is used to describe procedures that treat fractures by three methods: 1) without manipulation 2) with manipulation 3) with or without manipulation.

Open treatment: The CPT states this coding option is used to designate when the fracture is surgically opened (exposed to the external environment). In this instance the fracture (bone ends) is visualized and internal fixation used.

Note: The diagnosis of an open or closed fracture (from the ICD9) is not synonymous with an open repair (from the CPT). A patient can have a closed fracture that requires an open treatment. For example displaced unstable and comminuted fractures may require internal fixation.

Related Articles - orthopedic codes, coding confusion, icd-9-cm manuals, medical coding, medical billing, medical coding & billing, cpt codes, icd-9 codes, hcpcs codes,

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