Q&A: Coding fractures

CDI Strategies - Volume 16, Issue 48

5. Q&A: Coding fractures

Q: Please advise on the coding guidelines in ICD-10-CM regarding the coding of fractures and their specificity obtained from a radiology report. For example, a patient is diagnosed with ankle sprain but when radiology reads the x-ray it shows a fracture. Previous advice stated that we can code the fracture. Is this still valid for ICD-10-CM?

Can you also address if the following advice still applies: An outpatient encounter for pain with no site mentioned and an x-ray is done, and we are instructed to code pain of that site of the x-ray. Will the same advice be true in ICD-10-CM?

A: The AHA Coding Clinic 1st Quarter, 2013 answered this question by stating that the same advice would apply to more specific coding in ICD-10-CM.

A question sent to Coding Clinic asked about the specificity obtained from a radiology report and how it would be coded in ICD-10-CM. The question included examples regarding documentation of a sprain that the radiology report states is a fracture, and about site specificity, when the radiology report is more specific than the documentation in the medical record.

Coding Clinic answered the questions by stating that, “If the x-ray report provides additional information regarding the site for a condition that the provider has already diagnosed, it would be appropriate to assign a code to identify the specificity that is documented in the x-ray report.”

The same Coding Clinic also stated, “In the inpatient setting, abnormal findings are not coded and reported unless the provider indicates their clinical significance. If the findings are outside the normal range and the attending provider has ordered other tests to evaluate the condition or prescribed treatment, it is appropriate to ask the provide whether the abnormal finding should be added.”

Advice from AHA Coding Clinic 1st Quarter, 2017 Outpatient Laboratory, Pathology and Radiology coding states, “For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, it is appropriate to code any confirmed or definitive diagnosis documented in the interpretation. Do not code related signs and symptoms as additional diagnoses.”

Here is a relevant excerpt from the Official Guidelines for Coding and Reporting:  

Section I. Conventions, general coding guidelines and chapter specific guidelines

B. General Coding Guidelines.

13. Laterality - Some ICD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. If the side is not identified in the medical record, assign the code for the unspecified side. When a patient has a bilateral condition and each side is treated during separate encounters, assign the "bilateral" code (as the condition still exists on both sides), including for the encounter to treat the first side. For the second encounter for treatment after one side has previously been treated and the condition no longer exists on that side, assign the appropriate unilateral code for the side where the condition still exists (e.g., cataract surgery performed on each eye in separate encounters). The bilateral code would not be assigned for the subsequent encounter, as the patient no longer has the condition in the previously treated site. If the treatment on the first side did not completely resolve the condition, then the bilateral code would still be appropriate. When laterality is not documented by the patient’s provider, code assignment for the affected side may be based on medical record documentation from other clinicians. If there is conflicting medical record documentation regarding the affected side, the patient’s attending provider should be queried for clarification. Codes for “unspecified” side should rarely be used, such as when the documentation in the record is insufficient to determine the affected side and it is not possible to obtain clarification.

I think another interesting piece of information here has to do with the new Medicare Code Editor (MCE) that went into effect on April 1, 2022, regarding certain diagnosis codes when laterality is not specified. These code edits are used to detect and report errors in coding claims data. These types of errors include submitting a claim with an invalid diagnosis or procedure code, E-codes used as a primary diagnosis, sex conflict, or invalid age of a patient, etc., and require fixing prior to CMS paying the claim. This new edit will be specifically used for some of the diagnosis codes that have “unspecified” laterality instead of right, left or bilateral being specified.

The MCE states (bold added for emphasis), “In the inpatient setting, there should generally be very limited and rare circumstances for which the laterality (right, left, bilateral) of a condition is unable to be documented and reported.” Since the guidelines tell us that laterality can be captured using documentation from someone other than the provider or from a diagnostic report, such as an x-ray or MRI, it is hard to disagree with them.

Section I.C.13.a of the Official Guidelines for Coding and Reporting also states that, “Most of the codes within Chapter 13 have site and laterality designations. The site represents the bone, joint or the muscle involved. For some conditions where more than one bone, joint or muscle is usually involved, such as osteoarthritis, there is a “multiple sites” code available. For categories where no multiple site code is provided and more than one bone, joint or muscle is involved, multiple codes should be used to indicate the different sites involved.”

Editor’s note: Sharme Brodie, RN, CCDS, CCDS-O, CRC, CDI education specialist for ACDIS/HCPro, based in Middleton, Massachusetts, answered this question. Contact her at sbrodie@acdis.org.

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