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Are you clinical enough for ICD-10-PCS?

ICD-10-PCS requires coders to possess strong clinical knowledge as well as a solid foundation in anatomy and physiology. Coders need to understand what physicians are actually doing in certain procedures. Without an understanding of what is being done, coders can’t assemble the correct ICD-10-PCS code.

guy with question marks (2)Consider a Billroth II procedure. Do you know what the physician is actually doing? Do you know how it differs from a Billroth?

A Billroth II procedure is a surgical procedure in which an anastomosis is created between the stomach and the proximal loop of the jejunum. In case you’re wondering, a Billroth procedure involves removing the pylorus and creating an anastomosis of the proximal stomach directly to the duodenum.

If you know that a Billroth II is also called a gastrojejunostomy, or if your surgeon documents gastrojejunostomy, you’re in luck. ICD-10-PCS includes two listings for gastrojejunostomy in the Alphabetic Index.

Of course, two is not as good as one, but it gives us a place to start. Our two choices according to the Alphabetic Index are:

  • Bypass, stomach 0D16
  • Drainage, stomach 0D96

The only difference between the first four characters of the code is character three, the root operation. We determine the root operation based on the intent of the procedure. So in a gastrojejunostomy, what is the physician doing? He or she is creating an anastomosis, basically a surgical connection between two structures.

Look at the definitions of Bypass and Drainage. Bypass involves altering the route of passage of the contents of a tubular body part. Drainage involves taking or letting out fluids and/or gases from a body part. Based on the intent of the procedure, Bypass is our root operation.

In ICD-10-PCS, we assign codes based on the body part bypassed from to the body part bypassed to. Confused? Don’t be. The fourth character in the code is where the bypass began, in this case the stomach. The seventh character is where the bypass ends up, in this case, the jejunum.

We also need to know the approach:

  • Open
  • Percutaneous
  • Via a natural or artificial opening endoscopic

We also need to know what type of device was used. Remember, in ICD-10-PCS you only code devices that are left in the patient after the procedure. For an anastomosis, we are connecting one body part to another. The physician probably isn’t placing a device, but read the operative report to be sure.

For an open Billroth II without a device, we would report: 0D160ZA (bypass stomach to jejunum, open approach).

If you aren’t sure what a physician is doing during a common procedure, ask the physician to explain it or make friends with your clinical documentation improvement specialists. They can probably help you out as well. You still have time to figure out what clinical information you don’t know and what procedures you commonly code. Make the most of that time.

No coding from shorthand




detective with footprintsBP↑

It’s a texting world, and more and more we use shorthand in our everyday lives. What about shorthand in a medical record? Can you code from it?

First, let’s look at what kind of shorthand you might see. Physicians may use a +, ↑, or ↓. Those symbols could mean positive (like a pregnancy test), increased level, or decreased level, respectively. The problem is, they aren’t very clear or specific.

Na↑ could mean hypernatremia (elevated sodium) or it could just mean the sodium level has increased. Maybe the patient has a low sodium level and the physician is simply indicating that treatment to raise the level is working. It could mean the sodium level is a little high or significantly elevated. Maybe the physician just documented a slight elevation so he or she remembers to have it rechecked during the patient’s next encounter.

Bottom line: you just don’t know, so you can’t code from it.

So that means it’s time to query the physician, right? Well, it depends. First, make sure you review the entire record and see if the physician documented the information anywhere else more specifically. Maybe BP↑ was just a note on a summary sheet and in the history of present illness, the physician stated, “Patient’s blood pressure elevated.” No query needed. We have the information.

Maybe the physician didn’t document it more completely elsewhere. Is the condition clinically significant?

Hypernatremia is a CC, so it could affect MS-DRG assignment and the patient’s care. You should probably query.

↓BP could also be clinically significant because a low blood pressure could cause other health problems, such as dizziness, weakness, and fainting. Again, probably worth a query.

↓low chloride is probably not worth querying, because it isn’t associated with any adverse health effects.

If you have providers who routinely seem to document using symbols, work with them to eliminate the symbols and document in clear words. (because we can’t code from symbols in any coding system). The better the physician documents, the better the story of the patient becomes.

Avoid flaming food and spinning fans

Take it from today’s victims, er, patients, at the Fix ‘Em Up Clinic: not every idea is a good idea.

Flaming marshmallpwFirst in today is Jeff. He took part in a s’more eating contest at camp last night. I’ve personally never understood the appeal of burned marshmallows, but to each his own.

Jeff was so determined to claim the s’mores title that he ate a few marshmallows that were a little too hot. As in, they were on fire. And while fire eating is fine for professionals, for a kid at camp, it’s not such a great idea.

Dr. Sunni Daze examines Jeff and documents burns to the mouth, pharynx, tongue, and lips.

The burns of the mouth, pharynx, and tongue are easy. One code covers all three and it does not specify degree of the burn. Since this is Jeff’s initial visit, we would report T28.5XXA.

The lip burns require a little more information. We need to know what degree of burns Jeff suffered on his lips. Fortunately for him, Dr. Daze notes the burns are first degree, so we would report T20.12XA (burn of first degree of lip[s]).

ICD-10-CM does not include separate codes for the upper and lower lip, so T20.12XA covers one lip or both.

We also find the following note under pretty much all of the burn codes:

  • Use additional external cause code to identify the source, place and intent of the burn (X00-X19, X75-X77,X96-X98, Y92)

We definitely need an X00-X19 code, which in Jeff’s case is X10.1XXA (contact with hot food, initial encounter).

The X75-X77 codes are for intentional self-harm. Overeating burning marshmallows doesn’t quite qualify as planning to hurt yourself. Jeff just got caught up in the moment.

The X96-X98 are codes for assault. Again, not applicable in Jeff’s case.

For our place of occurrence, we’ll use Y92.833 (campsite as the place of occurrence of the external cause). Notice we do not need a seventh character for this code.

Our second patient Grace tried to change the direction of the fan by grabbing the cage that houses the blades. Turns out that wasn’t the best plan. That “squeeze” caused the blades to hit the cage and Grace’s fingers.

Fortunately, the fan wasn’t going fast enough to sever any of Grace’s fingers, but she does have some wicked-looking lacerations.

ICD-10-CM finger laceration codes are very specific, as in you need to know which hand and which finger is involved. You also need to know whether the nail is damaged and whether any foreign body remains in the laceration.

Let’s see what Dr. Daze documented:

14-year-old female with lacerations to the palm side of the right index, middle, ring fingers, no nail involvement. No foreign bodies remain in wounds. Flexor digitorum profundus tendon of index finger severed.

The first injury we’ll code is the severed tendon, because it is the most severe injury. If you look under laceration (because the tendon was lacerated, right?), the entry for tendon directs you to see Injury, muscle, by site, laceration.

Okay, so off to Injury, muscle, finger we go. And find all sorts of code options. The codes are divided into the forearm and hand level. We don’t have a code for finger level, so we’ll go with hand level.

However, we can code to the specific finger. In Grace’s case, that’s the right index finger and code S66.120A (laceration of flexor muscle, fascia, and tendon of right index finger at wrist and hand level, initial encounter).

The other codes for Grace’s misadventure would be laceration codes for the middle and ring fingers:

  • S61.212A, laceration without foreign body of right middle finger without damage to nail, initial encounter
  • S61.214A, laceration without foreign body of right ring finger without damage to nail, initial encounter

Dr. Daze is done for the day and so are we. Remember to make sure your food isn’t on fire before you eat it.

Increased specificity leads to better coding

ICD-10-CM includes 68,000 codes and ICD-10-PCS features 71,924 code choices. Scary numbers, right?

TipsNot according to Sue Bowman, RHIA, CCS, senior director of coding policy and compliance for AHIMA in Chicago.

All of those codes will actually make it easier to find the code that best represents either the patient’s diagnosis or the procedure the physician performed.

Some ICD-9-CM codes are vague. By now, you’ve probably seen the comparisons for fracture codes. ICD-9-CM may include only two code choices for a particular fracture (open or closed), while ICD-10-CM can offer more than 100 (sometimes more than 200) codes, which include laterality, specific site of the fracture, type of fracture, and encounter.

Sue likes to compare the code book to a phone book. If you look at the New York City phone book, you’ll find lots and lots of names. More than 8 million people call the Big Apple home. By contrast, Schenectady, New York, is home to slightly more than 66,000 people and requires a much smaller phone book.

You’ll still look up a name the same way. You just have more names to sort through in New York City.

Same holds true for ICD-10-CM. (ICD-10-PCS is very different than ICD-9-CM Vol. 3).

You still look in the Alphabetic Index, you still go to the Tabular List to double check the code. The only difference is you have more code choices.

Increase specificity makes it easier to assign a code because it takes some of the guess work out of the process, Sue says.

That’s especially true in ICD-10-PCS. The ICD-9-CM Vol. 3 codes are so vague that one code could represent more than 100 procedures. That about ambiguity!

With all of the code choices in ICD-10-PCS, you’re more likely to find a code that represents what the physician actually did. And that should save time in the long. It will certainly give us more accurate data about the patient and allow us to tell a better story about the patient’s health.

Get up to speed on diabetes changes

dont miss itThe new ICD-10 implementation date gives us more than a year to finish preparing for the big transition. So why learn about how to code diabetes in ICD-10-CM now?

“It’s never too early to start learning,” says Jillian Harrington, MHA, CPC, CPC-I, CPC-P, CCS, CCS-P, MHP. “By keeping the ball rolling, staff can continue to drive home those documentation improvement aspects to providers.”

Another advantage to starting now: “We as coders and CDI specialists can become experts in ICD-10-CM coding ourselves,” Jillian says. By becoming experts, we’ll know what is needed from a documentation standpoint and we’ll also know the coding guidelines before ICD-10-CM implementation.

Diabetes coding won’t really be harder in ICD-10-CM, Jillian says, but it will be different. The codes will look different, the documentation requirements will change, and you can’t use 250.00 after October 1, 2015. (Don’t worry, though, ICD-10-CM does have an equivalent code.)

Jillian will gives coders, CDI specialists, and clinicians the inside scoop on how to code for diabetes in ICD-10-CM during the live 60-minute webinar, ICD-10-CM Diabetes: Combine Coding and Documentation for Greater Specificity.

She will reveal how the new codes better represent a patient’s clinical picture and what information coders and CDI specialists need to see in the documentation to assign the most specific code. She’ll also review what the ICD-10-CM guidelines and Coding Clinic have to say about ICD-10-CM diabetes coding and offer some tips on getting physicians to improve their documentation.

Be sure to join us at 1 p.m. Thursday, August 14, for the live webinar. Come ready with questions for Jillian! She’ll answer live questions after her presentation.

And if everyone at your organization can’t make it to the live show, don’t worry, you get a free on-demand version of the webinar!

Coding for the Iceman

Otzi-Quinson (2)

“Otzi-Quinson” by 120 – Own work. Licensed under Creative Commons Attribution-Share Alike 3.0 via Wikimedia Commons –

Ötzi the Iceman suffered from atherosclerosis. A pair of hikers discovered Ötzi’s well-preserved mummy in the Ötztal Alps, near the border between Austria and Italy, in 1991. Since then, scientists have performed numerous tests on Ötzi and discovered a wealth of medical information.

In addition to his atherosclerosis, Ötzi also suffered from:

  • Lyme disease
  • Whipworm infestation
  • Tooth decay

He probably suffered a head injury, according to proteins in his brain, before being shot in the shoulder by an arrow and bleeding to death. And because of his advanced (for the time) age of 45, he also suffered from worn joints, which probably caused pain.

How would we code Ötzi’s various maladies in ICD-10-CM?

For his atherosclerosis, we need to know whether it is a native vessel or a bypass. Since they didn’t do bypass surgery in Ötzi’s day, we’ll go with native vessel. That leaves us with these choices:

  • I25.10, atherosclerotic heart disease of native coronary artery without angina pectoris
  • I25.110, atherosclerotic heart disease of native coronary artery with unstable angina pectoris
  • I25.111, atherosclerotic heart disease of native coronary artery with angina pectoris with documented spasm
  • I25.118, atherosclerotic heart disease of native coronary artery with other forms of angina pectoris
  • I25.119, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris

We also see a note to use an additional code, if applicable, to identify:

  • coronary atherosclerosis due to calcified coronary lesion (I25.84)
  • coronary atherosclerosis due to lipid rich plaque (I25.83)

The team that uncovered Ötzi’s atherosclerosis noted a buildup of calcium in his arteries, so we’ll need to add I25.84 as a secondary code.

On to Ötzi’s Lyme disease. That’s a pretty easy one because we only have one choice: A69.20.

If Ötzi suffered complications due to his Lyme disease, we would use one of these codes instead:

  • A69.21, meningitis due to Lyme disease
  • A69.22, other neurologic disorders in Lyme disease
  • A69.23, arthritis due to Lyme disease
  • A69.29, other conditions associated with Lyme disease

The whipworm infestation is also easy to code. When you look up whipworm in the ICD-10-CM Alphabetic Index, you find an entry for: whipworm (disease)(infection)(infestation) B79.

Because we know not to code only from the Alphabetic Index, we look up B79 in the Tabular List, where we find:

B79, Trichuriasis



whipworm (disease)(infection)

Next up is tooth decay. When we look up decay in the ICD-10-CM Alphabetic Index, we are directed to see Caries, dental. You may have already known that, but if not, the index directs you to the correct entry.

These codes require more information than just dental caries. For example, we need to know what kind of caries Ötzi had:

  • K02.3, arrested dental caries
  • K02.5-, dental caries on pit and fissure surface
  • K02.6-, dental caries on smooth surface
  • K02.7, dental root caries
  • K02.9, dental caries, unspecified

For caries on pit and fissure surfaces and those on smooth surfaces, we also need to know how far the caries penetrated:

  • Limited to enamel (fifth character 1)
  • Penetrating into dentin (fifth character 2)
  • Penetrating into pulp (fifth character 3)

ICD-10-CM does not require you to specify which teeth are involved.

What about Ötzi’s fatal injuries—the blow to the head and the arrow wound?

Scientists documented that he suffered a craniocerebral trauma with major bleeding in the back of the brain, along with a skull fracture. Unfortunately, they didn’t say exactly what type of fracture.

As for the bleeding, Ötzi likely suffered a brain hemorrhage caused by an artery in the brain bursting and causing localized bleeding in the surrounding tissues. You’ll find the codes for traumatic cerebral hemorrhages divided by side of the brain:

  • S06.34-, traumatic hemorrhage of right cerebrum
  • S06.35-, traumatic hemorrhage of left cerebrum
  • S06.36-, traumatic hemorrhage of cerebrum, unspecified

The codes also specify different times for loss of consciousness:

  • without loss of consciousness
  • with loss of consciousness of 30 minutes or less
  • with loss of consciousness of 31 minutes to 59 minutes
  • with loss of consciousness of 1 hours to 5hours 59 minutes
  • with loss of consciousness of 6 hours to 24 hours
  • with loss of consciousness greater than 24 hours with return to pre-existing conscious level
  • with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving
  • with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness
  • with loss of consciousness of any duration with death due to other cause prior to regaining consciousness
  • with loss of consciousness of unspecified duration

Because we don’t know if Ötzi lost consciousness or specifically where the hemorrhage occurred, we can’t assign a code. We would need to query Ötzi’s physician.

We’ve now come to Ötzi’s final injury: the arrow in the shoulder. The arrowhead entered the left shoulder blade and came to rest near Ötzi’s lung. Although it did not damage any internal organs, the arrowhead severed an artery and Ötzi bled to death.

If we look up laceration, blood vessel in the Alphabetic Index, we are directed to see injury, blood vessel. We find lots of codes for blood vessel injuries. These codes, not surprisingly, identify the location of the blood vessel and, in some cases, the actual blood vessel itself. For example, we can code an injury to the common carotid artery.

When we look at blood vessel, shoulder, we’re directed to see:

  • Specified, NEC – see injury, blood vessel, arm, specified site, NEC
  • Superficial vein – see injury, blood vessel, arm, superficial vein

We know we are not dealing with a superficial vein because the physician documented that the arrowhead ended up near the lung. Our most likely code is S45.812A (laceration of other specified blood vessels at shoulder and upper arm level, left arm, initial encounter).

And with that, we are at the end of the Iceman’s medical record.

The great outdoors is no place for the weak

Ah, the joys of camping. The fresh air, the beautiful scenery, the friendly forest creatures. Sounds like a great way to escape from the urban jungle and the daily grind.

Angry squirrelNice in theory, not so nice for Larry.

Larry headed off to the state park to spend some quality time with nature. He packed all the essentials—tent, stove, cell phone, skillet, sleeping bag, water, and of course, raw meat. Nothing like a good meal when you are out of doors.

Sadly for Larry, he forgot to pack matches, fuel for his stove, and enough ice for his cooler.

He also forgot to practice setting up his tent before setting off for the great outdoors. And Larry apparently is not very coordinated.

When he tried to set up his tent, he realized he also forgot to pack a hammer to drive the tent stakes into the ground. Not to be deterred, Larry found a really big rock to use instead. Apparently, Larry’s aim was off and instead of driving in the stake, he smashed his thumb.

If Larry sought treatment for his thumb injury, we would need to know:

  • Which thumb (Larry is right-handed, so he smashed his left thumb)
  • Whether the nail is injured (it’s not, Larry didn’t hit it that hard)
  • Episode of care (first visit)

For Larry’s thumb contusion, we would report S60.012A (contusion of left thumb without damage to nail, initial encounter).

Since he knows some basic first aid, Larry opens his cooler (with the raw meat inside), takes out some ice, wraps it in a spare shirt, and applies the ice-filled shirt to his throbbing thumb.

While he’s waiting for the pain to subside (he also forgot to pack some aspirin), Larry wanders over to sit on a boulder and enjoy the view. Alas, he forgot to close the lid on the cooler and the smell of Larry’s uncooked meat draws the interest of a mountain lion.

The mountain lion arrives to raid the cooler and Larry decided to defend his dinner. He snatches up a tree branch and attempts to ward off the mountain lion, who is unimpressed by Larry’s makeshift club. The mountain lion knocks the branch out of Larry’s hand with a nice loud growl, sending Larry fleeing for the safety of the nearest tree.

On the way to the tree, Larry trips over a log and does a face plant into the dirt on the other side. In the course of this trip, Larry cuts his forehead and twists his ankle.

If Larry seeks medical attention for these injuries, we need to know a lot more information.

For example, does any of the forest floor remain in Larry’s laceration? We have two code bases to choose from in ICD-10-CM:

  • S01.81-, laceration without foreign body of other part of head
  • S01.82-, laceration with foreign body of other part of head

Both codes will require a seventh character, and to make sure it’s in the seventh position we need to add an X placeholder. You’ll also note that the forehead does not have its own ICD-10-CM code. It’s simple “other part of the head.” Not to be confused with unspecified part of the head.

On to Larry’s sprained ankle. Again we need laterality, and this time we also need to know which specific ligament. If you aren’t familiar with the ankle ligaments, ICD-10-CM includes choices for:

  • Calcaneofibular ligament (S93.41-)
  • Deltoid ligament (S93.42-)
  • Tibiofibular ligament (S93.43-)
  • Other ligament, specifically the internal collateral and talofibular ligaments (S93.49-)

We also have a code for unspecified ligament (S93.40-), but we’re trying to avoid using unspecified codes.

Each of these codes requires two additional characters. The sixth character provides the laterality—right, left, or unspecified—and the seventh is the encounter.

If you find yourself about to report a code starting S93.409-, STOP. That code is an unspecified ligament of an unspecified ankle. That’s not going to cut it. At the very least, the physician should be documenting laterality. If he or she isn’t, you need to have a polite conversation about the importance of complete, accurate documentation.

It is highly possible that the physician doesn’t know which ligament, especially if he or she doesn’t deal with ankles much. So you could legitimately report an unspecified ligament. If the physician never provides that information, you might want to ask a CDI specialist to chat with the physician to find out why.

Now back to poor Larry. He has picked himself off the ground while the mountain lion is picking the steak out of the cooler. Deciding that discretion is the better part of valor, Larry continues for the safety of the tree. Unfortunately he forgot about his damaged thumb in his quest to climb the tree and all he succeeds in doing is annoying the tree’s resident squirrels.

The squirrels, who weren’t too sure about this visitor in the first place, are now very unhappy and vent their displeasure by pelting Larry with acorns. For furry little rodents, their aim is pretty good and they succeed in hitting Larry in the eye, and also in knocking out one of his teeth.

What type of eye injury did Larry sustain? Corneal abrasion (S05.0-)? Laceration of the eyeball (S05.3-)? Maybe it’s just a lacerated eyelid (S01.11-).

We’ll need laterality and the encounter to round out any of these codes.

For the tooth injury, we need to know whether the tooth is just cracked, in which case we would report K03.81.  If it’s actually fractured,  we need S02.5- with two placeholders and a seventh character.

Either way, we don’t need to know which tooth. ICD-10-CM isn’t that specific, yet.

Having by now had his fill of the great outdoors, Larry throws his gear back in his car and heads for the nearest hotel.

Combination codes and comorbidities

Inpatient coders and clinical documentation improvement specialists are very familiar with CCs and MCCs. After all, they help determine the MS-DRG assignment for a particular inpatient stay.

TipsICD-10-CM includes a lot more combination codes than ICD-9-CM, which eliminates the need for multiple codes to report a condition.

Say a type 2 diabetic patient also has gangrene. Dr. Smith documents the gangrene is due to diabetes. In ICD-9-CM, we would report two codes: 250.7x (diabetes with peripheral circulatory disorders) and 785.4 (gangrene). In ICD-9-CM, the gangrene is a CC.

In ICD-10-CM, we only need one code: E11.52 (Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene). What happens to the CC? We no longer have a secondary diagnosis to provide the CC. Do we lose out?

Never fear, the Cooperating Parties came up with a way to solve the case of the disappearing CCs and MCCs. In ICD-10-CM, certain codes, such as E11.52, act as their own CC or MCC. As long as the physician documents enough information for you to report the combination code, this new twist shouldn’t affect coding at all. It might actually make it easier.

Sleuthing for documentation details

Put on your deerstalker hat and grab your magnifying glass. It’s time to do our best Sherlock Holmes impersonation.

detective with footprintsWe just received a chart from Dr. Doolittle and we need to code the procedure. However, some of Dr. Doolittle’s documentation went astray (such as the clinical indications, diagnosis, and history), and this is all the information we have:

Confirmed identity of patient Jill, who was satisfactorily sedated. I used the MFL 1,000 for extracorporeal shock wave lithotripsy, delivering 1,000 shocks to the stone in the lower pole of the right kidney, and 800 shocks to the stone in the upper pole of the same, with change in shape and density of the stone indicating fragmentation. The patient tolerated the procedure well.

Which ICD-10-PCS code would we report?

Let’s start by determining what we know. Well, we’re in the Medical and Surgical section, which means our first character is 0.

The procedure involves the kidneys, which makes our body system the urinary system (second character T).

For the root operation, we need to figure out what Dr. Doolittle did. He documented “extracorporeal shock wave lithotripsy” as the procedure. When we look up lithotripsy in the ICD-10-CM, we find two possible root operations:

  • With removal of fragments, see Extirpation (taking or cutting out solid matter from a body part)
  • See Fragmentation (breaking solid matter in a body part into pieces)

Dr. Doolittle didn’t mention removing fragments, so it’s probably not Extirpation.

If you look up extracorporeal shock wave lithotripsy, ICD-10-PCS directs you to Fragmentation. So Fragmentation it is.

That gives us 0TF as our table. When we get to the table, we notice that the right kidney and the left kidney have their own body part values. We don’t have a bilateral kidney choice, so we’ll be reporting two codes, one for each kidney.

On to the approach. We have six choices in this table and no indication of an approach in the documentation, right? Actually wrong.

An extracorporeal medical procedure is one that is performed outside the body. That makes the approach external.

The table includes only one choice for a device and one for a qualifier, so the little grey cells get a break on the last two characters of our codes. Based on Dr. Doolittle’s documentation and our own sleuthing abilities, we would report:

  • 0TF3XZZ, fragmentation in right kidney pelvis, external approach

Now let’s go see if we can find the rest of Jill’s record.

Them’s the breaks

Julie comes into the Fix ‘Em Up Clinic with a seriously broken arm. Her son Jay left his toy fire engine on the stairs and Julie tripped over it. She threw her arms out to brace her fall. And then snap. Not a good sound to hear. Even worse was when she realized the bone was sticking out of her arm.

Dr. Setter examines Julie and orders x-rays to determine the specific types and locations of the fractures. Because Julie’s fractures are open, he immediately schedules her for surgery at the Stitch ‘Em Up Hospital.woman falling down stairs

When Dr. Setter gets the x-rays back, he determines that Julie suffered diaphyseal fractures involving the right radius and ulna. Hmm, I don’t think that’s enough information to get us to the correct ICD-10-CM codes.

Codes for fractures of the forearm live in category S52. And you’ll notice a lot of codes under S52. They are broken down into:

  • Ulna and radius
  • Specific part of the bone
  • Displaced and nondisplaced
  • Left and right
  • Type of fracture

However, none of them are for a diaphyseal fracture. Now what? Well, if we check our handy medical dictionary (in book form or online) we can find out that a diaphyseal fracture involves the shaft of a long bone.

We do have codes for fractures of the shaft of the ulna and the radius—many, many codes. So it looks like we’re going to have to query Dr. Setter, unless of course our radiologist documented the details we need.

When we check the radiologist’s report, we find documentation of a displaced transverse fracture of the shaft of the right ulna and a displaced comminuted fracture of the shaft of the right radius. Because Dr. Setter documented the fractures, we can pull additional details from the radiologist’s report.

Dr. Setter also noted this is Julie’s first visit, so we would report codes:

  • S52.221B for the ulna fracture
  • S52.351B for the radius fracture

One thing we don’t have is the extent of the soft tissue damage on the Gustilo-Anderson classification scale. We can query for it or just default to B (initial encounter for open fracture NOS) for our seventh character.

Given the seriousness of Julie’s fractures, Dr. Setter is admitting her to the Stitch ‘Em Up Hospital, where Dr. Breaker will perform surgery to stabilize the fractures.

Dr. Breaker documents an open reduction internal fixation (ORIF) of the right radius and right ulna. Be very careful with ORIF. Sometimes the physician calls it an ORIF, but actually reduces the bone (moves it back into place) before creating the incision to place the fixation device.

In Dr. Breaker’s notes, she documents making the incision prior to reducing the fractures. Note that we need to know this for both fractures. Because the radius and the ulna are separate body parts in ICD-10-PCS, we are going to report separate codes for them. It’s possible that one reduction was open and one was closed. Dr. Breaker documents the same procedure for both bones.

What root operation does ORIF fall under? Well, what is the intent of the procedure? Dr. Breaker is putting the pieces of the bone back into their normal position. Sounds a lot like Reposition (moving to its normal location, or other suitable location, all or a portion of a body part).

Now that we have our root operation (and our section, Medical and Surgical, and our body system, upper bones), we can head to table 0PS (that’s a zero at the beginning of the code, not a capital O—no capital O or I in ICD-10-PCS).

We know the body parts for our two codes: right radius (H) and right ulna (K). Now for the approach. Dr. Breaker documented an open approach, so our fifth character is 0.

Our sixth character is the device and our choices are:

  • 4, internal fixation device
  • 5, external fixation device
  • 6, internal fixation device, intramedullary
  • B, external fixation device, monoplanar
  • C, external fixation device, ring
  • D, external fixation device, hybrid
  • Z, no device

We can eliminate all but two of those choices very quickly because we know Dr. Breaker used an internal fixation device. We just need to know whether it is intramedullary. Remember to look at the device for each bone separately. Each bone gets its own code, so the devices may be different.

In this case, Dr. Breaker documents internal fixation device, but does not mention intramedullary. That makes our sixth character 4 for both codes. The seventh character is easy. We only have one choice—Z (no qualifier).

For Julie’s surgery we would report:

  • 0PSH04Z, reposition right radius with internal fixation device, open approach
  • 0PSK04Z, reposition right ulna with internal fixation device, open approach

When Julie comes back in for routine follow-up care, we will use the same main ICD-10-CM codes we used for the initial fractures, just with a different seventh character. That will help us track how well a specific treatment works for a specific injury and also let us keep track of how well Julie heals.