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ICD-10 Documentation: Tips and Examples for Complete ICD-10 Documentation

Tips and Examples for Complete ICD-10 Documentation:


Fracture coding is one area which will require a great deal more specificity in documentation for ICD-10 than for ICD-9.   

When documenting a fractured bone specify the following:

  • displaced or non-displaced
  • open or closed
  • which bone (be specific)
  • left, right or bilateral (if applicable)
  • distal, shaft or proximal (for long bones)
  • initial encounter or subsequent encounter for normal healing, delayed healing, non-union, mal-union, or for sequela.

Example 1:

Poor Documentation:

  • fracture metatarsal

Good Documentation:

  • Non-displaced, closed fracture 5th metatarsal, left foot, initial encounter

The above fracture code-set in ICD-9 consists of four codes.  825.25 closed fracture metatarsal bone, 825.29 closed fracture of metatarsal bone with tarsal bone, 825.35 open fracture metatarsal bone, 825.39 open fracture metatarsal bone with tarsal bone. 

ICD-9 does not allow for identification of the specific metatarsal bone (1st, 2nd, 3rd, 4th, 5th), laterality (left, right), episode of care (initial, subsequent, sequela), or type of fracture (displaced or non-displaced). 

ICD-10 requires all of this information.  The above fracture would be coded as S92.355A  There are 33 specific six digit codes listed for metatarsal fractures, each of which requires a seventh digit.  There are seven choices for the seventh digit in coding fractures.  This means the code-set for a metatarsal fracture consists of 231 codes.

Example 2:

Poor Documentation:

  • Fracture left hip

Good Documentation:

  • Open, type II fracture, neck of left femur, non-union

Again, ICD-9 does not allow for laterality (left, right), open fracture classification (type I, II, IIIA, IIIB or IIIC) or episode of care, initial, subsequent, or sequela.  The ICD-9 code for a hip fracture would be 820.8 – fracture of unspecified part of neck of femur, closed.  

The ICD-10 code for the above fracture is S72.002M.  This code-set also requires a 7th digit, which incorporates the classification of open fractures, Types I, II, IIIA, IIIB & IIIC, as well as initial encounter, subsequent for normal healing, delayed healing, non-union or mal-union, and sequela.

When documenting long bone fractures, it is also very important to indicate the precise location of the fracture.  Is it a proximal fracture of the femur?  If so, is it a fracture of the head, neck (midcervical, base), greater trochanter, lesser trochanter?  Each very specific fracture location has its own set of codes. 

It seems like an overwhelming amount of information, but the more specific you can be, the better.  ICD-10 has much greater specificity in its code sets, and consequently fewer non-specified codes.  As always, coders cannot make assumptions, they can only code what is documented.  Incomplete documentation will require coders to spend more time obtaining the correct information, ultimately slowing the billing process.  Providing complete documentation will go a long way to ensuring that the transition to ICD-10 is a smooth one that doesn’t hamper your cash flow.

In preparation for ICD-10 we will post regular tips and examples to our blog as we head towards the October 2015 implementation date. 

By: Heather E. Golfos, CPC, CANPC Coding Department Assistant Manager

On Monday, April 7, 2014

Categories: Compliance & Coding News

The information presented herein reflects general information that is current as of the date it was first published. Please check with your individual legal and/or compliance advisor(s) prior to taking any significant actions based upon the information and advice presented.

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