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2016 ICD-10 Ortho Fracture Worksheet

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“Build” the most accurate seven-character fracture code with this easy-to-use tool.

Are you scrambling to understand the new ICD-10-CM traumatic fracture codes? These seven character codes, with each number and letter representing specific information, can set even veteran coders’ heads spinning. For example, some of the information that may be found in fracture codes include:

  • the type of fracture,
  • specific anatomical site,
  • whether the fracture is displaced,
  • laterality,
  • routine versus delayed healing,
  • nonunions and malunions,
  • identification of type of encounter.

 

That’s why any tool that can help you easily select the most accurate code is vital to have on hand. Check out our 2016 ICD-10 Ortho Fracture Worksheet. This tool uses the PCS coding logic to break down these traumatic fractures into simple worksheets and allow you to build up to the full seven-character diagnosis.

Scenario: Suppose your physician sees a patient for increased pain in her ankle. She has had a previous trimalleolar fracture of the left ankle. After evaluation, he diagnoses a nonunion of her left trimalleolar fracture. What should you do?

So in this scenario, we know that we’re looking at the lower leg, specifically the ankle. That sends us to category S82 (Fracture of lower leg, including ankle). The best root code we have is S82.8---, so let’s look at that row.

(Note: Displayed below is the row that you need for this example, not the full 10 page worksheet.)

S82 – FRACTURE OF LOWER LEG, INCLUDING ANKLE

Anatomic Location (Characters 1-4)

Side or Type (Characters 5-6)

Encounter (Character 7)

OTHER (S82.8---)

1 = Torus of upper end*
2 = Torus of lower end*
3 = Upper and lower end
9 = Other

1 = Right
2 = Left
9 = Unspecified

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

4 = Bimalleolar/lower leg
5 = Trimalleolar/lower leg
6 = Maisonneuve’s
7 = Pilon

1 = Displaced/right
2 = Displaced/left
3 = Displaced/unspecified
4 = Nondisplaced/right
5 = Nondisplaced/left
6 = Nondisplaced/unspecified

Following that S82.8--- row, you will find “trimalleolar” (character 5). You would stay in that row again, to find “displaced/left” (character 2). Finally, you would apply K (Subsequent encounter for closed fracture with nonunion).

Heads up: Did we know if this fracture was displaced or nondisplaced? Coding guidelines specify that if displaced versus nondisplaced is not indicated, the default is displaced.

Solution: You should report S82.852K (Displaced trimalleolar fracture of left lower leg, subsequent encounter for closed fracture with nonunion). That wasn’t too hard, was it?

Don’t be caught scratching your head when it comes to ICD-10-CM fracture codes again. Have the 2016 ICD-10 Ortho Fracture Worksheet at your fingertips, and you’ll turn these complicated diagnoses into easy-to-build seven digit codes. Order today!

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