Are your clinicians aware of the increased documentation needs for fractures in ICD-10?

ICD-10 implementation is coming ever closer and it looks like there will not be a delay.  Is your agency proactive in educating clinicians and physicians on additional documentation needed to code in ICD-10-CM?  Each month I’ll be sending out documentation tips to assist you with this transition because there are many diagnoses in ICD-10 that require more specific information than is currently needed in ICD-9.

Specifically, the types of information I will be covering is as follows:  Increased site specificity, laterality, combination codes, increased specificity related to histologic behavior of certain neoplasms, increased specificity related to type of injury, use of fracture classification systems, Intraoperative and postprocedural complications, and revised terminology.

Identifying the specific site of injuries will be important for ICD-10 because separate codes will be required for each and every injury unless a combination code is available.  Take a look at fracture of neck of femur; currently providers only  need to identify the site of femoral fracture head/neck ( and identify whether the fracture is open or closed.  However, in ICD-10-CM, documentation must have increased specific information.  Site identification has doubled; the head and neck sections have been separated and subtrochanteric has been moved to its own section.  You will need to identify which side of the body the fracture occurred, right or left side and whether the fracture is closed or open.  If the fracture is open, additional information needs to be gathered from the physician to identify the Gustilo classification, which identifies types I, II, IIIa, IIIb, or IIIc.

Finally, the episode of care will need to be identified, which includes whether the patient’s fracture has delayed healing, malunion, nonunion, routine healing or if the patient has a sequela (late effect) because of the fracture.  There are currently 16 potential episode of care selections and without specific information, the OASIS will not be accepted because the selection is for the 7th (required) character completes the ICD-10-CM fracture code.

ICD-9-CM Coding and Documentation Requirements

Identify site of femoral fracture:

  • Head/Neck
    • base of neck
    • epiphysis
    • intracapsular section, unspecified
    • midcervical
    • other specified site
    • unspecified part
  • Pertrochanteric
    • intertrochanteric section
    • subtrochanteric section
    • trochanteric section, unspecified (includes greater or lesser)

Identify fracture as:

  • Closed
  • Open

ICD-10-CM Coding and Documentation Requirements

Identify site of femoral fracture

  • Neck
    • base of neck
    • epiphysis
    • intracapsular (subcapital), unspecified
    • midcervical
    • other specified site
    • unspecified part
  • Head
    • articular
    • other specified site
    • unspecified part
  • Pertrochanteric
    • apophyseal
    • greater trochanter
    • intertrochanteric
    • lesser trochanter
    • unspecified trochanteric site
  • Subtrochanteric

Identify fracture status:

  • Displaced
  • Nondisplaced

Identify laterality:

  • Right
  • left
  • unspecified (don’t use this, you know which leg has been effected).

Identify fracture as:

  • Closed
  • OpenGustillo Classification
    • Type I or II, or open NOS
    • Type IIIA, IIIB, IIIC

Identify episode of care:

  • Initial
  • subsequent with
    • delayed healing
    • malunion
    • nonunion
    • routine healing
  • Sequela

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