musculoskeletal injuries in ICD-10-CM. Coding Compliance ... · CMS still believes that the physician’s history and CMS proposes change for physician certifications with inpatient

AUGUST 2014Volume 17Issue No. 8

Briefings on

Coding Compliance

Strategies

Your inpatient coding, billing, documentation, and regulation resource

Most facilities know that CMS amended Title 42 of the Code of Federal Regulations (CFR), §412.3, last year to define the criteria for inpatient admission as the expectation and certification by the admitting phy-sician that the patient stay will cross two midnights.

The physician makes the determination based on complex medical factors, including patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event.

The new 2-midnight rule replaced the previous requirement for inpatient admission on signs/symp-toms and intensity of services with a 24-hour bench-mark that did not have to be certified.

While CMS did not make any changes to the 2-mid-night rule in the FY 2015 IPPS proposed rule released April 30, it did propose in the CY 2015 OPPS pro-posed rule released July 3 to eliminate the physician certification requirement for short-duration inpatient admissions.

CMS still believes that the physician’s history and

CMS proposes change for physician certifications with inpatient hospital admissions

Clinically Speaking Robert S. Gold, MD, explains what makes pathologic fractures different from traumatic fractures.

ICD-10-CM training toolTake this 10-question quiz to determine how well you understand coding of musculoskeletal injuries in ICD-10-CM.

Focus on fracture coding changes in ICD-10-CMLearn about the major changes to frac-ture coding and documentation.

Brush up on types of bone fracturesKristi Stanton, RHIT, CCS, CPC, CIRCC, reviews the characteristics of different types of fractures.

P5

P8

P9

P12

Inside: Coding Q&A insert

physical and progress notes should support the need for a stay spanning two midnights, so it left in place the 2-midnight rule definition and the requirement for an explicit inpatient order on or before the beginning of the inpatient stay.

The proposed change will lessen the administrative burden on hospitals and their medical staff for shorter inpatient stays because the majority of hospital in-patient stays are less than 20 days, says Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA-ap-proved ICD-10-CM/PCS trainer, of Fremont, Califor-nia, a healthcare professional with more than 30 years of experience.

“With the additional clarification of 20 days, this should help hospitals in monitoring these longer stays,” Bryant says. “There are still some operational steps to put in place and a need for physician aware-ness and engagement.” She says she would like to see CMS create a certification template that all facilities would use, similar to a standard advance beneficiary notice.

August 2014Briefings on Coding Compliance Strategies

2 HCPRO.COM © 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

Follow UsFollow and chat with us about all things healthcare compliance, management, and reimbursement. @HCPro_Inc

Briefings on Coding Compliance Strategies (ISSN: 1098-0571 [print]; 1937-7371 [online]) is published monthly by HCPro, a division of BLR, 75 Sylvan St., Suite A-101, Danvers, MA 01923. Subscription rate: $269/year. • Briefings on Coding Compliance Strategies, P.O. Box 3049, Peabody, MA 01961-3049. • Copyright © 2014 HCPro, a division of BLR. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, a division of BLR, or the Copyright Clearance Center at 978-750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781-639-1872 or fax 781-639-7857. For renewal or subscription information, call customer service at 800-650-6787, fax 800-639-8511, or email [email protected]. • Visit our website at www.hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. • Opinions expressed are not necessarily those of BCCS. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

EDITORIAL ADVISORY BOARDLori Belanger, RN, BSN, RHITInpatient Coder/CDI SpecialistNorthern Maine Medical Center Fort Kent, Maine

Paul Belton, RHIA, MHA, MBA, JD, LLMVice President Corporate ComplianceSharp HealthCare San Diego, California

Gloryanne Bryant, RHIA, CCS, CDIP, CCDS HIM ConsultantFremont, California

William E. Haik, MD, FCCP, CDIPDirectorDRG Review, Inc. Fort Walton Beach, Florida

James S. Kennedy, MD, CCSPresidentCDIMD Smyrna, Tennessee

Laura Legg, RHIT, CCS HIM and Coding Consultant Renton, Washington

Monica Lenahan, CCSManager of Coding Education and ComplianceRevenue Management Centura Health Englewood, Colorado

Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDSDirector of Coding and HIMHCPro, Inc. Danvers, Massachusetts

Jean Stone, RHIT, CCS, CDIPManager of Clinical Documentation Integrity Program/HIMSLucile Packard Children’s Hospital at Stanford Palo Alto, California

Senior Managing EditorMichelle Leppert, [email protected]

This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, a division of BLR, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission.

The proposed change may be a way for CMS to address a lawsuit filed in April by the American Hospital Association (AHA) alleging the adoption of the new certification requirements last year was arbitrary and capricious, according to Kimberly A.H. Baker, JD, director of Medicare and com-pliance for HCPro, a division of BLR, in Danvers, Massachusetts.

“I think this is a big win for providers as a way of reducing unnecessary documentation,” Baker says.

The 2-midnight rule is a burden on hospitals and physicians because the standards and documenta-tion requirements surrounding the rule deny hos-pitals appropriate Medicare reimbursement for reasonable and medically necessary care, according to the AHA’s suit.

Another potential problem for hospitals involves cases where the physician dictates the information but does not sign the certification before the patient leaves the hospital. Currently if this happens on short-stay inpatient cases, the facility will not receive payment,

Baker says. In the 2015 OPPS proposed rule, CMS specifically

cites this proposed change as a way to reduce the administrative burden of the 2-midnight rule. The physician certification is one of the more onerous administrative requirements of the 2-midnight rule, Baker adds.

The 2-midnight rule definition of an inpatient admission

The 2-midnight rule’s criteria for an inpa-tient admission includes both a benchmark and a presumption.

The 2-midnight benchmark instructs providers to admit a patient if the provider expects the patient’s stay will cross two midnights of medically necessary time based on the patient’s presentation and other factors. Explicit exceptions include:• Inpatient-only procedures• Unforeseen deaths or transfers to other inpatient

facilities

Briefings on Coding Compliance StrategiesAugust 2014

3HCPRO.COM© 2014 HCPro, a division of BLR. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or 978-750-8400.

• Mechanical ventilation initiated during the visit

Under the 2-midnight presumption, CMS in-structed Recovery Auditors to consider any inpatient stay that crossed two midnights to be medically necessary. Auditors will not review these cases unless there is evidence that the facility is trying to game the system.

“As such, the 2-midnight rule provides physi-cians with a bright line for the criteria for inpatient admission,” says James S. Kennedy, MD, CCS, CDIP, president of CDIMD-Physician Champions in Nashville.

“The certification required that physicians put their medical decision-making on paper, giving more ammunition to defend inpatient stays that, for one reason or another, lasted less than the expected two midnights. Without this documentation, most facilities are vulnerable to Recovery Auditors play-ing Monday morning quarterback as they deny the additional resources inherent to the inpatient stay ordered by a physician with face-to-face patient contact.”

Documentation of the medical decision-making does not guarantee hospitals and physicians will win an appeal, but it does support the physician’s thought process at the time of the encounter.

Physicians are also vulnerable if they bill their professional services as inpatient (e.g., CPT codes 99221–99223) in good faith, but their Recovery Auditor amends the patient status to outpatient or observation for an inpatient stay of less than two midnights. The physician would not necessarily have the documentation essential to defending the inpa-tient claim, Kennedy says.

Physician certificationCMS’ proposed amendment, if approved, will most

likely become effective on January 1, 2015. Until then, physicians must still provide certification for an inpa-tient stay prior to the patient’s discharge, as required by 42 CFR §412.3.

While a certification at the time of the inpatient order may not be required after January 1, 2015, one

will be required for prolonged inpatient stays prior to (not on or after) the 20th hospital day.

As described by CMS in its January 30, 2014, clarifi-cation on physician certification, the current certifica-tionsmust include these four elements:

1. Authentication of the practitioner order: The physician certifies that he or she ordered the inpatient services in accordance with the Medicare regulations governing the order. This includes certification that hospital inpatient services are reasonable and necessary. For ser-vices that CMS does not consider inpatient-on-ly, the physician also certifies that the services are appropriately provided as inpatient services in accordance with the 2-midnight benchmark. The requirement to authenticate the practitio-ner order may be met by the certifying physician signing or countersigning the inpatient admis-sion order.

2. Reason for inpatient services: The physi-cian certifies that the admission is for:• Inpatient medical treatment or medically

required inpatient diagnostic study• Special or unusual services for outlier cases

under the applicable prospective payment system for inpatient services

3. The estimated (or actual) time the beneficiary requires or required in the hospital: The physician certifies the estimated time in the hospital the beneficiary requires (if the certification is completed prior to discharge) or the actual time in the hospital (if the certification is completed at discharge). The physician can reflect the estimated or actual length of stay in the progress notes, where the practitioner discusses the assessment and plan. The provider may document the expected or actual length of stay in the order or a separate certification or recertification form, but CMS will also accept it if discussed in the progress note’s assessment and plan or as part of routine discharge planning.

4. Any plans for post-hospital care: The phy-sician certifies what care, if any, the beneficiary requires after discharge from the hospital.



The proposal to remove the physician certification does not change the criteria for an inpatient admission described in 42 CFR §412.3, says Kennedy. The OPPS proposed rule emphasizes that physicians still need to determine whether a patient needs inpatient care and document their reasoning for the inpatient order in the admission and subsequent notes. Removing the certifi-cation requirement does not relieve these documenta-tion requirements.

“The inpatient certification encourages physicians to outline their medical decision-making for admitting a patient as an inpatient in a manner sanctioned by CMS,” Kennedy adds.

A challenge that providers face is what will make an encounter audit-proof, he says. If a patient with chest pain spends one night in the hospital when he or she was expected to spend two nights, should that patient have been admitted as an inpatient or placed in outpa-tient observation?

“These can be templated as part of a computerized physician order entry system for high-risk conditions, such as chest pain, syncope, and the like, relieving the physician from having to memorize off-the-shelf crite-ria like InterQual that auditors don’t necessarily follow anyway,” Kennedy says. “These templates encourage complete documentation of patient conditions essential to good patient care with the added benefit of promot-ing complete and precise ICD-10-CM coding.”

For that reason, Baker suggests hospitals retain this templated information because it is a good documenta-tion practice.

The downside to retaining the physician certification requirement is that not all physicians complete certifi-cation before the patient is discharged, especially with short stays.

Without a completed certification, the hospital can-not bill for the inpatient services, says Baker. “That’s a huge penalty.”

In some ways, CMS already removed the certification requirement by stating that the elements for the certifi-cation could be in other documentation, Baker says. The certification does not have to be a separate document.

“Before you decide not to bill because you lack certi-fication, look through the record to see if you can find the elements of the certification signed before dis-charge in other documents,” Baker says. “CMS allows

the certification to be reflected in other documents, so simply document where you found the elements so you can provide that to an auditor if you are questioned about the certification.”

Stays over 20 days and outliersUnder the proposed change, physicians would

still be required to complete the certification for any prolonged hospitalization prior to day 20. If the pa-tient is likely to be hospitalized for that length of time, providers must consider whether the patient should be in a short-term or long-term acute care hospital long before day 20, Kennedy says.

He challenges the need for a physician certification for prolonged inpatient stays. While uncommon, if a patient requires a stay of that length, it should be clinically obvious that the inpatient care is necessary.

Hospitals are already financially incentivized to reduce the length of stay even on outlier cases; while outlier payments are intended to help offset the costs of treating patients who require very expensive care, this reimbursement often does not cover the actual costs of caring for the patient. Adding a certification requirement gives Recovery Auditors authority to deny payment for care rendered if, for some reason, the hospital fails to obtain the physician certification prior to day 20.

Outlier cases are not always obvious—in many instances, hospitals are unaware they are triggering an outlier payment, Baker says. Many of those outliers will occur before day 20 of the stay.

Currently, hospitals qualify for outlier payments when the hospital’s charges (adjusted by the hospital’s cost-to-charge ratio) exceed a certain threshold amount.

The only way for hospitals to really predict outli-ers is to have revenue cycle staff and CDI specialists look at cases and determine a working MS-DRG, then determine what the outlier threshold is for that MS-DRG, Baker says.

“You can get outliers for all kinds of different rea-sons,” Baker says.

Timing of physician certification for prolonged hospital stays

The certification for outliers has always existed and hospitals have always supposed to calculate



when a case would qualify as an outlier to obtain the certification, but few hospitals actually did so. “We can’t really ask CMS how to [determine outliers before submitting claims] because we were sup-posed to be doing it all along,” Baker says, “Never-theless, that is what we are going to have to do to get this right.”

If CMS insists on having the physician certifica-tion for outliers before the patient leaves the hos-pital, facilities could run into problems. Because of the difficulty in calculating outlier payments, Baker believes hospitals should be able to obtain the phy-sician certification before submitting a claim, not just before the patient is discharged.

“You can get an outlier on a trauma case that is transferred shortly after admission,” Baker says.

For example, a patient may come into the ED with traumatic injuries and be admitted, but then end up transferred to a hospital better equipped to treat the injuries.

“CMS takes the outlier threshold and make it a per diem threshold,” Baker says. “If you exceed that, you could have a one-day stay where you transferred the patient and end up with an outlier because outliers are proportional when you have a transfer. How are hospitals going to identify this?” H

EDITOR’S NOTERead the 2014 IPPS final rule at http://tinyurl.com/m9tsbsj. See the AHA’s announcement of its lawsuit and its reasoning at http://tinyurl.com/mkzgrlm. For more on CMS’ physician certification requirements, see http://tinyurl.com/q8v2dcm.Read the 2015 OPPS proposed rule at http://tinyurl.com/q57nqah.

The path to pathologic fractures: How to get there from here in ICD-10-CM

by Robert S. Gold, MD

To start, you don’t just follow the Yellow Brick Road. That only works in Kansas.

In ICD-10-CM, you need to communicate with the medical staff about the specific elements that are important for pathologic fractures, because the coding is different than it used to be and it’s so different from traumatic fractures.

A traumatic fracture is easy because orthopedic surgeons, ED physicians, and radiologists will invari-ably document sufficient pieces of that puzzle, leaving the episode of care as the only thing you have to worry about.

The part that’s tough is that orthopedic surgeons, ED physicians, and radiologists invariably tell you little about the pathology or the circumstances of the event to help you identify when the fracture is, or could be, pathologic.

We need to understand a few issues to get started, so let’s begin with some definitions. A fracture is a fracture. A broken bone, whether dwisplaced or

nondisplaced, whether all the way through or on only one side of the bone, whether caused by torque or repeated pressure or penetrating object, whether open or closed—it’s a fracture.

Next, some bones are normal and others are abnormal. Abnormal bones may be bones that:• Don’t have enough calcium in them • Don’t have enough phosphate or bone matrix • Have too much of something that makes them

brittle • Have something in them that creates uneven

character of the bone, such as a bone cyst or a metastatic or primary malignant deposit

There’s a disease of the bone at some point—or, truly, a disease throughout the patient’s whole body.

Factors that can cause pathologic fracturesNow, let’s look at how ICD-10-CM classifies these

particular fractures:• M80 Osteoporosis with current pathologic

fracture



– M80.0 Age related osteoporosis – M80.8 Other osteoporosis (drug induced, idiopathic, disuse, etc.)

• M81 Osteoporosis without current pathologic fracture

• M84 Disorders of continuity of bone—the other fractures (and other odd things)

– M84.3 Stress fracture – M84.4 Pathologic fracture, not elsewhere classified

– M84.5 Pathologic fracture in neoplastic disease

– M84.6 Pathologic fracture in other disease—name and code the underlying disease

Okay, first we see that our friend osteoporosis is divided into two major categories:• Osteoporosis that is associated with the aging

process • Other causes of osteoporosis that might occur in

people who are not particularly aged, although an older patient may have osteoporosis (or osteope-nia) due to other causes

Strictly speaking, osteopenia signifies that the patient has less than the normal amount of bony material in the bones; osteoporosis exists when this deficiency is visible, as on x-rays. Osteopenia is lower bone density than normal, but not enough to be considered osteoporosis.

So if it’s evident that other conditions exist—quadriplegia, cerebral palsy, calcium or vitamin D deficiency as in rickets, long-term use of steroids or anticancer treatment for prostate cancer, some diuretics and proton pump inhibitors—we might think that the patient’s injury could be eligible for classification as a pathologic fracture due to other causes of osteoporosis.

Next we see what many physicians mistakenly think is the only cause of pathologic fractures—ma-lignancy. Now, the real issue is that the classifica-tion is by “neoplasm,” and that could mean a neo-plasm that’s either malignant or benign.

Primary cancers of bone include osteosarcoma, chondrosarcoma, fibrosarcoma, and Ewing’s sar-coma. Bone marrow cancers can lead to weakness

and pathologic fractures, especially acute leuke-mia. Plasma cell myeloma (or multiple myeloma), which accounts for almost half of primary malig-nancies of bone, is associated with lytic lesions of the bone in 50% of the cases; in these cases, it leaves the bone at risk for fractures through the lytic areas. Metastatic cancer can get to the bone from the prostate, breast, kidney, thyroid, or lung most commonly.

Benign neoplasms of bone include osteoma, osteo-chondroma (either single or multiple), chondroblas-toma, enchondroma, giant cell tumors of bone, and various other permutations.

Then we have other conditions such as bone cysts, fibrous dysplasia of bone, osteogenesis im-perfect, Marfan’s syndrome, and other congenital or hereditary causes of bone weakness or structural abnormality.

Defining a pathologic fractureOkay, now we have a fracture documented, and we

may have notation somewhere that a condition exists. So is it a pathologic fracture or not?

The definition of a pathologic fracture is a fracture through diseased bone due to forces inadequate to have fractured a normal bone.

Next, according to the structure of pathologic frac-tures, we have to identify the anatomic area with the fifth character, the specific bone and laterality with the sixth character (for those bones with right and left counterparts), and the episode of care with the sev-enth character.

As opposed to traumatic fractures, for the M8- series of codes, it doesn’t seem to matter if the fracture was open or closed, so we’re only left with a few of the episode of care codes: • A, initial encounter• 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



Orlando, Florida—October 23–24, 2014

The Sixth Annual 2014 Medicare Compliance Forum pairs

leading Medicare experts with revenue cycle and compliance

professionals from the field to provide a unique combination of

solid regulatory guidance and practical solutions to enhance

your organization’s policies and procedures. It features three

tracks:

• Strategies for defending audits and appealing claims

• Determining patient status and optimizing utilization

review

• Navigating through the revenue cycle

This year’s hot topics include the following:

• The 2014 OPPS final and 2015 OPPS proposed rules

and their impact on the audit landscape for hospitals

• What the 2-midnight rule means for patient status and

medical necessity

• New guidance on Part A to B inpatient rebilling

The 2014 Medicare Compliance Forum

• How to implement policies to receive accurate payment

for packaged and separately billable labs

• How to optimize your utilization review committee by

understanding the Conditions of Participation, reviewing

real-world examples of successful utilization reviews,

and engaging the physician advisor to strengthen your

utilization review committee determinations

The 2014 Medicare Compliance Forum offers two

exciting pre-conferences October 22!

• Inpatient Versus Outpatient: A Soup to Nuts Menu for

Success

• Tricks of the Trade: Uncovering and Optimizing Medicare

Resources

For more information or to register, visit hcmarketplace.com

or call HCPro customer service at 800-650-6787.

Register by August 20 to enjoy early-bird pricing!

Fracture examplesLet’s look at a couple examples and figure out

where we are.A 56-year-old man was up in a tree, cutting limbs

after a lightning strike where they were danger-ously overhanging his kitchen. During this process he slipped and fell, landing on both feet and then onto his back. Pain in his left ankle and along his spine led him to call 911, and he was transported to the hospital. X-rays revealed a fracture dislocation of the left tibia and ankle mortise along with com-pression fractures of L-3 and L-4 with surrounding blood seen in the paraspinous muscles. X-rays also identified that he had lytic lesions at these sites and in his right shoulder, pelvis, and skull. A biopsy done during the reduction and fixation of the ankle fracture led to diagnosis of multiple myeloma. Is this a pathologic fracture? If so, which category of pathologic fracture, which bone, which side, and which episode of care?

An 82-year-old woman was serving her husband some chicken noodle with matzah ball soup. She leaned across the table to fasten his napkin under his chin (he always makes such a mess!) and heard a crack, accompanied by severe back pain. She pressed the button around her neck, stating, “Help, I’ve fallen and I can’t get up.” EMS arrived and transported her to the hospital, where the physi-cian identified a new compression fracture of L-3 along with old compression fractures of T-8 and T-9. She’s on no specific medications and has been in good health with good nutritional status. Is this a pathologic fracture? If so, which category of patho-logic fracture, which bone, which side, and which episode of care?

Got it? H

EDITOR’S NOTEDr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician CDI programs including needs for ICD-10. Contact him at 770-216-9691 or [email protected] answers to the fracture examples appear on p. 11.



Training tool: ICD-10-CM quiz

1. What is the correct ICD-10-CM code for tennis

elbow involving the right elbow?

a. M77.01

b. M77.02

c. M77.10

d. M77.11

2. Which ICD-10-CM code should you report for

juvenile rheumatoid arthritis with systemic onset in

the right wrist?

a. M08.231

b. M08.232

c. M08.241

d. M08.242

3. What is the correct ICD-10-CM code for calcium

deposits in the bursa of the left wrist?

a. M71.431

b. M71.432

c. M71.441

d. M71.442

4. What is the correct ICD-10-CM code for Staphylo-

coccal arthritis of the left hip?

a. M00.041

b. M00.042

c. M00.051

d. M00.052

5. What is the correct ICD-10-CM code for an

abscess in the bursa of the right shoulder?

a. M71.011

b. M71.012

c. M71.021

d. M71.022

6. What is the correct ICD-10-CM code for a recurrent

dislocation of the right ring finger?

a. M24.441

b. M24.442

c. M24.444

d. M24.445

7. What is the correct ICD-10-CM code for prepatellar

bursitis of the left knee?

a. M70.41

b. M70.42

c. M70.51

d. M70.52

8. What is the correct ICD-10-CM code for a spontaneous

rupture of the flexor tendon in the left thigh?

a. M66.332

b. M66.342

c. M66.352

d. M66.362

9. What is the correct ICD-10-CM code for adolescent

idiopathic scoliosis of the lumbosacral region?

a. M41.07

b. M41.116

c. M41.127

d. M41.27

10. What is the correct ICD-10-CM code for adult

osteochondrosis of the cervicothoracic region of

the spine?

a. M42.11

b. M42.12

c. M42.13

d. M42.14

Use this 10-question quiz to determine how well you understand ICD-10-CM coding for diseases of the musculoskeletal

system and connective tissue.



Focus on fracture coding changes in ICD-10-CM

The section of codes that expanded most in ICD-10-CM involves orthopedic injuries, especially fractures.

In ICD-9-CM, coders may only have two choices for a particular fracture. For example, a fracture of the shaft of the humerus only has two possible ICD-9-CM codes—812.21 for a closed fracture and 812.31 for an open fracture.

In ICD-10-CM, fractures of the shaft of the humerus fall under subcategory S42.3-, which includes eight subdivisions that specify the type of fracture, such as greenstick or comminuted. Each subcategory includes three codes to indicate laterality—left, right, or unspeci-fied. Five of the categories further specify whether the code is displaced or non-displaced.

All of the codes in subcategory S42.3- require a seventh character to identify the encounter. Coders have seven options when it comes to seventh charac-ters in S42.3-.

Guidelines and defaultsICD-10-CM does include two defaults for fractures.

If a fracture is not documented as displaced or nondis-placed, code it as displaced. If a fracture is not docu-mented as open or closed, code it as closed.

The most difficult aspect in coding fractures is that a fracture not documented as displaced or non-displaced is automatically considered displaced, says Kristi Stanton, RHIT, CCS, CPC, CIRCC, AHIMA-approved ICD-10-CM/PCS trainer, AHIMA ICD-10 ambassador, and senior consultant with the Haugen Consulting Group in Denver.

“Just know that it is assumed, unless the physician specifically tells us that it’s non-displaced, that that fracture was not in a normal position,” Stanton says.

Coders need to make sure that they look at the entire record and all the documentation. “Sometimes, if it’s a really nasty open fracture, they may not really come out and call it an open fracture,” Stanton says. “But as you look at the operative report, you can tell that it really was. Remember to go with your default guideline and that there is no shopping in the ICD-10 index. So you’ve got to go specifically with what the physicians say.”

For every fracture, coders will need to identify

the bone as well as where on the bone the fracture occurred, says Kim Carr, RHIT, CCS, CDIP, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, AHIMA ICD-10 ambassador, and clinical documentation direc-tor for HRS in Baltimore. For example, is the fracture at the head or the shaft, the proximal or distal end?

“That’ll be another type of documentation you’re going to need,” Carr says. Coders will also need the laterality and the episode of care. If physicians are not currently providing this information, consider begin-ning to query now so they become used to providing it before the ICD-10 transition.

Seventh character The seventh character for ICD-10-CM fracture codes

denotes the encounter. The specific choices vary by frac-ture category, so coders need to look at the beginning of the category and section to find which seventh character applies.

“First of all, these must be in the seventh character position,” Stanton says. “Some of the codes that we

Fracture coding checklist

Kim Carr, RHIT, CCS, CDIP, CCDS, clinical documen-

tation director for HRS Coding in Baltimore, provided this

quick checklist for coders to use when assigning a fracture

code in ICD-10-CM:

• Determine cause

– T raumatic or pathologic?

• Determine location (use radiology reports to find miss-

ing details)

– Which bone?

– Which part of the bone?

• Determine laterality

• Determine encounter type for seventh character

– Which encounter?

– Is it an open fracture of a long bone?

She also cautions coders to read the codebook carefully

because the tabular entries can be confusing.



have only have four or five characters, so we use an X as a placeholder.”

All fractures will have the option of three basic seventh character extension options:• A, initial encounter• D, subsequent encounter• S, sequela

Be careful not to confuse initial encounter with first visit. “What you really have to look at for the ICD-10 code is whether the patient is receiving active treat-ment or have they moved on to subsequent treatment,” Stanton says.

Active treatment could include surgery, an ED visit, or evaluation and treatment by a new physician. “As long as the patient is receiving active treatment, they get an A,” Stanton says.

A subsequent encounter (seventh character D) includes:• Cast change or removal• Removal of an external or internal fixation device,

which is common if the patient experiences pain or other complications

• Medication adjustment• Other aftercare and follow-up visits following injury

treatment

A sequela (seventh character S) is exactly like a late effect in ICD-9-CM. “Whatever was a late effect in ICD-9 is now a sequela in ICD-10,” Stanton says.

Some fracture categories, such as S42 (fracture of shoulder and upper arm) include these seventh character choices:• 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

Three categories of fractures feature even more seventh character possibilities. For categories S52 (fracture of forearm), S72 (fracture of femur), and S82

(fracture of lower leg, including ankle), coders will choose one of the following seventh characters:• A, initial encounter for closed fracture• B, initial encounter for open fracture type I or II• C, initial encounter for open fracture type IIIA, IIIB,

or IIIC• D, subsequent encounter for closed fracture with

routine healing• E, subsequent encounter for open fracture type I

or II with routine healing• F, subsequent encounter for open fracture type IIIA,

IIIB, or IIIC with routine healing• G, subsequent encounter for closed fracture with

delayed healing• H, subsequent encounter for open fracture type I

or II with delayed healing• J, subsequent encounter for open fracture type IIIA,

IIIB, or IIIC with delayed healing• K, subsequent encounter for closed fracture with

nonunion• M, subsequent encounter for open fracture type I

or II with nonunion• N, subsequent encounter for open fracture type

IIIA, IIIB, or IIIC with nonunion• P, subsequent encounter for closed fracture with

malunion• Q, subsequent encounter for open fracture type I

or II with malunion• R, subsequent encounter for open fracture type

IIIA, IIIB, or IIIC with malunion• S, sequela

The types for these seventh characters refer to the Gustilo-Anderson classification, which applies to open fractures of the long bones, says Carr.

The Gustilo-Anderson classification also captures the severity of open fractures. It groups fractures into three main categories: type I, type II, and type III, which is further divided into three subcategories: A, B, and C.

The Gustilo-Anderson categories are defined by three characteristics:• Mechanism of the injury• Extent of the soft tissue damage • Degree of the bone injury involved

While coders can use the description of an ulcer to



code the stage in ICD-10-CM, they cannot use the de-scription of the amount of soft tissue damage to assign a type on the Gustilo-Anderson classification, Carr says. The physician must specifically state the type.

Coding orthopedic aftercareICD-10-CM also includes changes to how coders re-

port orthopedic aftercare. In ICD-9-CM, coders report a V code for physical therapy or other aftercare.

ICD-10-CM does include a code for orthopedic aftercare—Z47.89 (encounter for orthopedic after-care). “However, we do not use this code for orthopedic aftercare for injuries,” Stanton says. “What we report instead is the code for the injury with the seventh char-acter for subsequent care.”

For example, a patient is admitted to a rehab facil-ity for physical and occupational therapy following an open reduction internal fixation for a fracture of the left intertrochanteric section of the femoral neck.

“Currently in ICD-9, if we were to code this case, it would go to a V57.89 as our principal [diagnosis] and an 820.21 for the intertrochanteric fracture,” Stanton says. This case groups to MS-DRG 945 (rehabilitation with CC/MCC).

In ICD-10-CM, coders will report S72.142D (dis-placed intertrochanteric femoral neck fracture, sub-sequent encounter for closed fracture with routine healing) and no secondary diagnosis. Code S72.142D groups to the lower-paying MS-DRG 561 (aftercare, musculoskeletal system & connective tissue without CC/MCC).

Coding examplesA patient comes into the ED with a fracture of

his right clavicle. The coder assigns code S42.021A (displaced fracture of shaft of right clavicle) for the initial visit.

The patient returns later with a nonunion of the fracture. “For his subsequent visit, the coder reports S42.021K, which is the same code, but the seventh character is now letting us know that this is a subse-quent encounter and he has a nonunion,” Stanton says.

The unfortunate patient then suffers post-traumatic shortening of the right clavicle due to a fracture of the clavicle shaft three years ago. Again, the coder assigns

the exact same base code, but the seventh character now represents the sequela (S42.012S), Stanton says.

What happens when a patient comes in for treat-ment of malunion of a fracture and has never been seen before for that fracture? “On one hand, you kind of want to go with initial because the patient has never had treatment, but on the other hand, we kind of want to go with that subsequent seventh character because it would specify malunion,” she says.

Coding Clinic, Fourth Quarter 2012, instructs coders to report a seventh character A. “The fact that this is the first time that the patient is presenting for treatment takes precedence over the malunion,” Stanton says.

Coding for initial versus subsequent malunion can become tricky very quickly, she says. Coders need to carefully read the documentation to determine whether the patient is seeking treatment for the first time for the fracture.

“You cannot code a subsequent seventh encounter if the patient has not presented for treatment before,” Stanton says. H

ICD-10 quiz answers

Here are the answers to the ICD-10-CM training quiz on

p. 8:

1. D

2. A

3. B

4. D

5. A

Here are the answers to the case studies from Dr.

Gold’s “Clinically Speaking” column on p. 5:

Example 1 is a traumatic fracture even though it was a

diseased bone due to neoplasm. The trauma would have

fractured a normal bone. Code this the usual way to cap-

ture a traumatic fracture and add a code for the multiple

myeloma.

Example 2 is a pathologic fracture due to age-related

osteoporosis.

Both are initial episodes of care.

6. C

7. B

8. C

9. B

10. C



Brush up on types of bone fracturesFractures can be open or closed, displaced or non-

displaced. Different types of fractures show different characteristics.

“Do beware of the terminology within a medical record that will alert you to whether or not a fracture is open or closed,” says Kristi Stanton, RHIT, CCS, CPC, CIRCC, AHIMA-approved ICD-10-CM/PCS trainer, AHIMA ICD-10 ambassador, and senior con-sultant with the Haugen Consulting Group in Denver.

The list of open fractures is easier to memorize be-cause it is a lot shorter. Open fractures include any-thing that is compound or infected, Stanton says. “That makes sense to me, because it’s open, so bacteria was able to get to the fracture site.”

Other open fractures include missile fractures, punc-ture fractures, or any fracture that has a foreign body.

Below is a breakdown of eight different types of fractures: • Comminuted: a fracture in which the bone is bro-

ken in more than two pieces or fragments• Greenstick: an incomplete fracture with bending

of the bone involving the convex side• Linear: a fracture that extends parallel to the long

axis of a bone but does not displace the bone tissue• Oblique: a fracture line that runs at a diagonal

along the long axis of the bone, with the bone corti-ces of both fragments in the same plane

• Segmental: fracturing in two different locations

or segments of the same bone• Spiral: a fracture caused by twisting or rotation-

al forces, with a fracture line that twists or spirals along the long axis of the bone

• Torus: a bending or buckling of the bone without a complete fracture that occurs only in children due to the softness of the bone

• Transverse: a fracture line that is straight across the long axis of the bone, also described as a right angle to the long axis

What happens when the physician doesn’t document the type of fracture in the record? Can coders use the radiology report in coding? This question was posed to the AHA’s Coding Clinic for ICD-9-CM, and it has been presented to Coding Clinic again for ICD-10-CM/PCS, Stanton says.

“What they’ve come back with and answered is that yes, you can use specific parts of bones, laterality, etc., from the radiology report,” she says. “But don’t forget that your doctor has to actually document the fracture somewhere in the record.”

If the ED physician documents that the patient has a femur fracture, the coder can flip back to the radiology report and see that it was an intertrochanteric fracture of the right femur and use that information.

Coding Clinic for ICD-10-CM/PCS provided this guidance in the First Quarter 2013 issue. H

Types of bone fractures

A supplement to Briefings on Coding Compliance Strategies

A monthly service of Briefings on Coding Compliance Strategies

AUGUST 2014

Coding Q&A

Q Can you provide any guidelines for the time frame for an admission order written immediately fol-

lowing a procedure when it’s an unexpected inpatient-only procedure?

A If the service is performed on an emergency ba-sis, Medicare just says in a couple places “imme-

diately after” and doesn’t talk a lot more about it. In the case of converted procedures (outpatient service start-ed converted to inpatient-only) CMS representatives have said there is no grace period and deferred to the MACs. At least one MAC has published a Q&A stating that the orders should be written when the procedure is complete. If it goes much beyond postop, you’re not going to be able to claim the order was written immedi-ately after.

Q Does CMS require at least one overnight stay for an inpatient-only procedure? We have had several

cases that leave the day of the procedure.

A Intuitively you would think that’s true, but the fact that the procedure is designated inpatient-

only makes the patient de facto appropriate for inpa-tient regardless of how long they stay or whether they occupy an inpatient bed. If the patient requires ad-ditional hospital care, absolutely they can stay. But there’s no requirement for them to stay overnight.

The patient can be discharged out of postop if that’s appropriate clinically for this patient. Just bear in mind the inpatient-only list was made for the average elderly Medicare patient, but we have some really healthy baby boomers on Medicare now. I think that for some of the inpatient-only procedures, those patients can go home the same day, and that’s perfectly appropriate.

Q A patient comes in for a laparoscopic cholecys-tectomy at 1600 hours. During surgery, the phy-

sician has to convert it to an open procedure or the patient is found to have a gangrenous gallbladder, but no inpatient order was written until the next morning when a case manager reviewed it. Does that order count?

A Unfortunately, this open abdominal procedure is on the inpatient-only list, so you do not have

a billable procedure here. You do have an inpatient ad-mission the following morning. As long as the patient’s stay meets the 2-midnight benchmark, which is likely if the patient had a gangrenous gallbladder, then you can be paid for the medical care related to that medical condition. But the surgery code should not be listed on the claim because it happened before the order.

These are the ones I’m afraid the Recovery Auditors can data-mine. Under Medicare’s guidelines it’s very clear that if there is no inpatient order before the pro-cedure, it’s not inpatient. Especially in cases when the order comes the next day, the Recovery Auditors are going to be able to data-mine and determine the pro-cedure date was before the date of the inpatient order. Bing, that’s a denial. They don’t even have to pull re-cords; the way it was billed shows it wasn’t covered.

Some providers believe the three-day window would make this appropriately combined to the inpatient ad-mission because it occurred with a window. However, CMS has made it clear that if an inpatient-only proce-dure is provided before the order, they consider it non-covered and therefore not eligible for combining to the inpatient claim. Again, this kind of case is one to be concerned about because of the way hospitals tend to bill. The procedure is provided, the inpatient order is written the next day, and it’s medically necessary so no

We want your coding and compliance questions!The mission of Coding Q&A is to help you find an swers to your urgent coding/compliance questions.

To submit your questions, contact Briefings on Coding Compliance Strategies Senior Managing Editor Michelle Leppert, CPC, at [email protected].

A monthly service of Briefings on Coding Compliance Strategies

A If there was an admission order before the proce-dure, the patient will be considered an inpatient

and would not be considered outpatient simply because the procedure didn’t go forward. As long as we had a valid, signed order, that patient is an inpatient and we would bill that as a canceled inpatient procedure.

Medicare talked about cancelled inpatient procedures in some of the 2-midnight guidance and that canceled inpatient procedures would nevertheless be appropriate under 2-midnight if it was an unexpected cancellation.

This patient got all the way into the OR, and then we cancelled the procedure. Maybe the patient had a reac-tion to the anesthesia, or we started the procedure and the patient had some kind of an event. Then we recov-er them, and because we didn’t do that inpatient-only procedure, the patient may be able to go home right af-ter recovery. Nevertheless, that patient is an inpatient because you admitted him or her before the procedure, and then you actually get that DRG for that procedure.

On the outpatient side there’s a reduction when we cancel procedures. There is not under the DRG system. But if you think about it, you used many of the resourc-es that you would otherwise use, and with the DRGs we’re supposed to have some winners and some losers. It’s an averaging payment system.

As long as an inpatient-only procedure is medical-ly necessary, and we could not have determined before the patient was admitted that we couldn’t go forward with the procedure, the patient is an inpatient under the 2-midnight rule.

Editor’s note: Kimberly A.H. Baker, JD, di-rector of Medicare and compliance for HCPro, a division of BLR, in Danvers, Massachusetts, an-swered these questions.

one questions the admission. When this goes to cod-ing, the coders will assign an ICD-9 procedure code for the gallbladder procedure because it occurred during the overall encounter. Because the inpatient- only list is published by CPT codes, the provider may not even realize that the procedure is inpatient-only or stop to think when the order was written because the total care was medically necessary as inpatient. The issue is the timing of the order, and because the order was writ-ten substantially after the procedure, the inpatient-only gallbladder procedure is not covered and should not appear on the inpatient claim. Nevertheless, the claim goes out that way, and then the Recovery Auditor comes and takes your money back.

Some providers have opted to put a case manager in the postop area, where they can assist with status after procedures and also watch for these sorts of inpatient-only procedures. If you don’t have sufficient staff to do this, you might consider training recovery room staff to prompt physicians for orders for procedures that convert.

One provider put in place a process where case man-agers would actually go through postop every 2–3 hours, look at every patient in the recovery area, and see if the patient had had an open procedure or any procedure that the case manager knew had converted during the procedure.

This facility found that certain procedures start lapa-roscopically and convert to open quite often. The case managers look for these converted procedures and get the orders in the recovery area. This facility had re-ceived a large number of denials for not having that in-patient order written until the next day, so this process was implemented to address this issue.

Q A patient came in for an inpatient-only procedure. The intention is that the physician would admit

the patient as an inpatient. The procedure was canceled in the OR. How would you bill that?

Coding Q&A is a monthly service to Briefings on Coding Compliance Strategies subscribers. Reproduction in any form outside the subscriber’s institution is forbidden without prior written permission from HCPro, a division of BLR. Copyright © 2014 HCPro, a division of BLR, Danvers, MA. Telephone: 781-639-1872; fax: 781-639-7857. CPT codes, de scriptions, and material only are Copyright © 2014 American Medical Association. CPT is a trademark of the American Medical As sociation. All rights reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The American Medical Association assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use.

BCCS, P.O. Box 3049, Peabody, MA 01961-3049 • Telephone 781-639-1872 • Fax 781-639-7857

Documents

musculoskeletal injuries in ICD-10-CM. Coding Compliance ... · CMS still believes that the physician’s history and CMS proposes change for physician certifications with inpatient