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Nonunion, malunion, or delayed healing?

FeetPoor Wendy. Shortly before Christmas, she stubbed her toe, really hard. However, no bruise appeared and her toe didn’t swell up, so she thought nothing of it. Three weeks later, she stretched her feet in bed and felt excruciating pain in the toe.

She came into the Fix ‘Em Up Clinic to see Dr. Setter, who confirmed that Wendy had fractured her toe. Dr. Setter provided a special shoe for Wendy to wear and told her to rest the foot as much as possible.

Three months later, Wendy’s broken toe hasn’t healed so she is back to see Dr. Setter. Wendy told Dr. Setter that because of the bad winter weather she was unable to wear the special shoe all of the time. She also stated that she is occasionally bothered by pain in the toe.

Dr. Setter ordered a new set of x-rays to make sure Wendy did not fracture the toe a second time. After comparing the old and new x-rays, Dr. Setter documents that the fracture is the same one Wendy suffered in December. He noted that the fracture is non-healing and is considering more aggressive treatment, including possible surgery.

How would we code Wendy’s fracture in ICD-10-CM? Basically, the same way we would have coded it in December, just with a new seventh character.

For fractures, we need to know:

  • Laterality
  • Specific site
  • Encounter
  • Open or closed
  • Displaced or non-displaced

We can gather some of this information from the x-ray that Dr. Setter reviewed. For example, the x-ray report identifies the fracture as a non-displaced fracture of the medial phalanx of the second right toe.

We don’t have any documentation that identifies the fracture as open or closed, but we do have a default (closed) in ICD-10-CM.

For a closed, non-displaced fracture of the medial phalanx of a right lesser toe, we would report S92.524-.

Now we have to decide which seventh character to use. For all codes in category S92 (fractures of the foot and toe, except ankle) we have seven possible seventh characters:

  • A, initial encounter for closed fracture
  • B, initial encounter for open fracture
  • D, subsequent encounter for fracture with routine healing
  • G, subsequent encounter for fracture with delayed healing
  • K, subsequent encounter for fracture with nonunion
  • P, subsequent encounter for fracture with malunion
  • S, sequela

We can eliminate B (we’re dealing with a closed fracture) and D (obviously, the fracture isn’t healing normally).

What about A? The Official Guidelines for ICD-10-CM Coding and Reporting instruct us to use A (and B) when the patient is receiving active treatment, such as:

  • Surgical treatment
  • Emergency department encounter
  • Evaluation and treatment by a new physician

Dr. Setter documents that he may need to operate on Wendy’s toe, but he isn’t doing it at this visit. He is also not a new physician and Wendy is not in the ED. So we can eliminate A.

A sequela is a late effect, something that shows up after an injury heals. It also isn’t a choice in this case because Wendy’s fracture hasn’t healed.

That leaves us with three choices for a subsequent visit:

  • Delayed healing
  • Nonunion
  • Malunion

We can also eliminate malunion. A malunion is a fracture that healed but in less than an optimal position. Again, Wendy’s fracture hasn’t healed so it can’t be a malunion.

Now things get tricky. Delayed healing and nonunion are very close in definition.

A nonunion occurs when a fracture fails to heal, according to the American Academy of Orthopedic Surgeons. Delayed union or healing is when a fracture takes longer than usual to heal.

Dr. Setter documented “non-healing” which is kind of a hybrid term. We may need to query Dr. Setter for clarification because ICD-10-CM doesn’t give us any information on how to differentiate between the two.

Sign up for CMS’ final end-to-end testing week

news blocksYou have one more chance to participate in CMS’ end-to-end testing. The agency is currently looking for approximately 850 volunteers for the June 1-5 testing week. You can volunteer on your MAC’s website.

CMS already completed one successful end-to-end testing week and the second is scheduled for April 27-May 1.

Why volunteer for end-to-end testing since CMS is continually conducting acknowledgement testing? With end-to-end testing, you not only find out whether your claim is accepted, you also get Remittance Advice. Always good to know that the claim made it the whole way through the system and not just in the door.

If you have already been accepted for end-to-end testing, you can still submit claims during the upcoming testing weeks. But you don’t need to sign up again. You’re all set.

We would love to hear from anyone who has participated in the end-to-end testing with CMS or any other vendor. Let us know how it went by emailing Steve Andrews at If you are planning to participate in either of the upcoming CMS testing weeks, we’d also love to hear from you.


No pot of gold for you

Pot of goldLiam spent this St. Patrick’s Day on a fruitless quest for a pot of gold.

He powered up for his quest by having a few glasses of green Guinness beer for breakfast. Turns out it’s not a good idea to try and make Guinness green. It requires an excessive amount of green dye.

As a result, Liam ended up suffering from:

  • 0X1A, toxic effect of ethanol, accidental (unintentional), initial encounter
  • 6X1A, toxic effect of paints and dyes, not elsewhere classified, accidental (unintentional), initial encounter

You’ll find those codes by looking in the Table of Chemicals and Drugs, just like you do in ICD-9-CM.

However, Liam decided a little poisoning was not going to deter him from his pursuit of fame and fortune (mostly fortune). So he headed back out to follow the rainbow only he could see. Hmm, perhaps Liam also has a little R44.1 (visual hallucinations) going on.

The (imaginary) rainbow leads him into the deep, dark woods, where instead of finding a friendly leprechaun, he encounters some decidedly less friendly woodland creatures. Or at least that’s his story when he arrives back at the Fix ‘Em Up Clinic with numerous bite marks, abrasions, and lacerations.


Out, out darn clot

shutterstock_86443981Poor Wile E. Coyote is headed for surgery. As you might recall, Wile E. suffered a subdural hematoma following a collision with a cliff on Friday the 13th. Dr. Frankenbean decided to try conservative treatment first, but alas, our favorite super genius is not bouncing back from this latest injury.

A CT scan showed a 6.6 mm subdural hematoma and Wile E. is showing significant lethargy and confusion. Dr. Frankenbean has decided that he needs to evacuate the hematoma.

How will Dr. Frankenbean perform this procedure? Actually, let’s back up a step. What procedure will Dr. Frankenbean perform? He can elect to drill a burr hole in Wile E.’s skull and suction out the hematoma. Or he could decide to perform a craniotomy, which creates a larger opening in the skull.

As a historical aside, burr holes and craniotomies have literally been around since prehistoric times. Forty of 120 skulls found at one burial site in France dated to 6500 B.C. show evidence of this type of procedure, formerly called trepanation.

Dr. Frankenbean decides to perform a craniotomy and evacuation procedure on Wile E. and transfers the patient to the Stitch ‘Em Up Hospital. Brain surgeries are inpatient procedures and if you check CMS’ inpatient-only list, you’ll find most brain surgery codes, including those for craniotomies, on that list.

So we know Wile E. will meet medical necessity for this inpatient admission. What would his principal diagnosis be? S06.5X2A (traumatic subdural hemorrhage with loss of consciousness of 31 minutes to 59 minutes, initial encounter).

How do we know that? When Wile E. arrived at the Acme ED Friday, Dr. Frankenbean documented a traumatic subdural hematoma with a loss of consciousness of 48 minutes. Wile E. was in observation before being admitted as an inpatient, so we’re still using the same ICD-10-CM code. Even if Dr. Frankenbean had discharged Wile E. and the coyote returned because he wasn’t feeling better, we would still use S06.5X2A. We will use the seventh character A when the patient is receiving active treatment, including surgery.


A bad day to be a genius

CliffPoor Wile E. Coyote, Friday the 13th has not been kind to our favorite super genius.

Wile E. arrived at the Acme ED decidedly the worse for wear after his latest encounter with a certain speedy bird and another less-than-stellar Acme product.

Wile E. purchased roller skis in an attempt to increase his speed and allow him to nab his choice of prey. At first, things looked pretty good. Wile E. was in hot pursuit of his prospective dinner when said meal made a U-turn at the end of a cliff. Sadly, Wile E. did not see the cliff edge coming and continued to ski forward into space.

He maintained enough momentum that he initially appeared likely to land safely on the cliff across the way. However, this being Friday the 13th and Wile E. being the unluckiest coyote to ever live, gravity got the better of him. Instead of landing on the smooth top of the opposite cliff, he slammed into the side. To make matters worse, he then plummeted to the bottom of the gorge.

At the Acme ED, Dr. Frankenbean undertook a thorough examination of Wile E.’s wounds.

According to Dr. Frankenbean’s documentation, Wile E. suffered multiple facial fractures consistent with hitting a rock wall at speed. So we have some traumatic fractures. The question is, which bones did Wile E. break?

ICD-10-CM does include a code for unspecified fracture of facial bones (S02.92-) and if you look up fracture, face, that’s where the Alphabetic Index sends you. But is that the best code to use?


Watch out for that tree

SleddingMelissa took her four nephews sledding over the weekend to the boys’ delight. They had a great time. Aunt Melissa, however, didn’t escape the adventure unscathed. While descending the (not really) deadly slope, Melissa and 10-year-old Eamonn went off course and headed toward a tree. Being the brave aunt, Melissa managed to turn the sled just enough so she only smashed her thumb into the tree. Eamonn escaped injury (except to his pride—he was the only one not to make it the whole way down the hill).

Melissa thought nothing of her mashed thumb until three days later when it was so bruised and swollen her coworker hounded her to go to the Fix ‘Em Up Clinic.

Dr. Frosty examines Melissa and documents significant swelling and bruising, as well as tenderness and pain. He sends her for an x-ray to rule out a thumb fracture and instructs her to come back the following day. In his documentation, he lists the diagnosis as “rule out thumb fracture.”

What can we code for Melissa’s visit? Since she was seen on an outpatient basis, we cannot code a thumb fracture because the diagnosis was not established. If she had been an inpatient, we could code the rule out, probable, and suspected diagnoses as if they were present (see the ICD-10-CM Official Guidelines for Coding and Reporting, II.G).

That means we need to code Melissa’s symptoms. But first, we need to know which thumb Melissa injured. ICD-10-CM specifies laterality for hands (arms, legs, eyes, ears, etc.). All of the codes that include laterality also include an unspecified option, but you shouldn’t need them. Physicians should already be documenting that information.

And Dr. Frosty did. When we review his notes, we learn Melissa mashed her right thumb.

Since we don’t have a definitive diagnosis of a fracture, we can only code for the established diagnosis, which in Melissa’s case is a contusion. Dr. Frosty did not mention any damage to the nail, so we would report S60.011A (contusion of right thumb without damage to nail, initial encounter).

Melissa is off to schedule an x-ray for her thumb and hope nothing’s broken.


I said what I meant and I meant what I said

question marksWe want physicians to be very clear in their documentation about what’s wrong with the patient and what the physician did to make that patient better. Our friends over at the Association of Clinical Documentation Improvement Specialists spend their professional lives working to get more precise, detailed, accurate, no-room-for-interpretation documentation.

Why all the fuss about specificity? Different people interpret things different ways. My colleagues sometimes hate me for playing devil’s advocate and saying, someone could take that to mean Y instead of X.

Relevant case in point: Earlier this week, AHIMA emailed its members imploring them to call members of Congress to oppose an ICD-10 delay. AHIMA’s Margarita Valdez, senior director of Congressional relations, heard that Chairman of the House Rules Committee Pete Sessions, R-Texas, was drafting (or looking to draft) language for another ICD-10 delay.

My colleague Steve Andrews reached out to Sessions’ office asking for verification. In very short order, a member of Sessions’ staff replied that the Congressman is meeting with physicians about their concerns regarding ICD-10, but no legislation has been drafted.

I also heard from a blog reader who told me she had spoken to a staff member for Rep. Rob Woodall, R-Ga. That staff member had spoken to Sessions’ staff, who told him that Sessions has no plans at present to introduce legislation for another delay of ICD-10. (That’s a massive amount of hearsay, because it’s at best fourth-hand information, but still, we’ll take what we can get for now.)

At first glance, that looks like a win. No legislation, no delay, right? Not exactly. Here’s where playing devil’s advocate comes in.

Sessions had not drafted legislation and has no plans to introduce legislation. However, no one claimed Sessions isn’t looking to add language to an existing (or future) bill to delay ICD-10. It’s nitpicking, but we are talking about politicians.


Notice the notes when coding autism

shutterstock_86443981A new article in the Journal of the American Medical Association (JAMA) Psychiatry shows a strong link between genetics and autism. That’s not an unusual or completely unexpected outcome. Scientists have known for some time that genetics plays a role in autism. The new study suggests genetic influences on autism to be between 74%–98%. You have to be a JAMA Psychiatry subscriber to read the complete article, but BBC News helpfully reported on the findings.

While scientists and physicians aren’t sure of the exact cause of autism, they—and the general public—do know that physicians are more commonly diagnosing autism. Keep in mind that autism is a spectrum of disorders, not a single condition. Some patients are mildly impaired by their symptoms, while others are severely disabled.

ICD-9-CM offers one code for autism with two possible fifth digits:

  • 299.00, autistic disorder, current or active state
  • 299.01, autistic disorder, residual state

If the state is unspecified, default to 0.

We do have one additional code choice for Asperger’s syndrome—299.8x (other specified pervasive developmental disorder). You will use either a 0 or 1 as the fifth digit just as you do for autism.

Since ICD-10-CM is more detailed, you might expect to find more code choices. Actually, you don’t.


Tell Congress no more delays

phone-on-deskJust when we were starting to feel really good about ICD-10’s chances of being implemented, AHIMA has learned that Chairman of the House Rules Committee Pete Sessions, R-Texas, is looking to draft language to delay ICD-10. The chairman is seeking support from his colleagues in Congress, according to an email from Margarita Valdez, senior director of Congressional relations for AHIMA.

AHIMA is urging HIM professionals to call Rep. Michael Burgess, R-Texas, at (202) 225-7772 and state that you support ICD-10 implementation in 2015.

Here are some talking points from AHIMA:

  • We need the code sets in 2015!
  • A recent GAO report supports ICD-10 readiness.
  • Small physician practices are expected to spend between $1,900 and $6,000 to transition to the new code set. This is much lower than previous reports. The study can be found on


Remember to eat your fiber

Joe came into the Stitch ‘Em Up Hospital for a colonoscopy and therapeutic polypectomy.

HCPro_template-KOnce Joe was under, Dr. Ben E. Full performed a digital rectal exam, which showed good sphincter tone. Dr. Full then advanced a video colonoscope through Joe’s rectum and into the cecum. Dr. Full documented that the mucosa was normal looking throughout, but noted a few diverticula in the sigmoid colon. Dr. Full also identified a rectal polyp in the proximal rectum, approximately 5 mm in size. Dr. Full removed the polyp using hot biopsy technique and sent it off to the lab for a pathology report.

The pathology report stated, “hyperplastic polyp,” which is a benign growth, so Joe doesn’t need to worry about cancer today. However, Dr. Full does prescribe a high-fiber diet for Joe’s diverticulosis and tells Joe to schedule a follow-up colonoscopy in three years.

How would we code Joe’s surgery? Let’s start with the diagnosis codes. The first thing we know is Joe has a polyp. To select the correct ICD-10-CM code, we need to know the location (and we do)—in Joe’s case, in the rectum. When we look up polyp, rectal in the ICD-10-CM Alphabetic Index, we find two choices:

  • Nonadenomatous, polyps with no malignant potential, including hyperplastic polyps, hamartomas, juvenile polyps, pseudopolyps, lipomas, and leiomyomas
  • Adenomatous, benign (noncancerous) growths that may be precursor lesions to colorectal cancer

We know Joe’s polyp is hyperplastic, so we would report K62.1 (rectal polyp). Under K62.1, you’ll see an Excludes1 note. These notes tell you that the two conditions are mutually exclusive. You can’t code one with the other.

So you would never report K62.1 with D12.8 (adenomatous polyp). You always code to severity, so the cancer supersedes a benign polyp.