On behalf of the American Society for Surgery of the Hand, I'd like to welcome everyone to ICD-10 webinar on fracture coding. This webinar is the second in an ASSH webinar series dedicated to ICD-10. Information regarding additional webinars in this series will come soon. Before I introduce our speaker, I would like to go over a few housekeeping items. Tonight's call is being recorded. You can access the recording within three business days at ASSH.org in your e-learning portal. You can send your questions throughout the program via the web presentation. Go to the chat pod located in the lower left corner of your screen, type your question in the text box, then click the send message button. Our speaker will answer your questions during the final portion of tonight's webinar. A copy of today's presentation is available to download in the handouts tab located on the left side of your screen. If you have any technical problems, you can press star zero and an operator will assist you, or you can send a message in the chat pod in the lower left corner of your screen. I would now like to turn it over to Mary Legrand, who is a coding and reimbursement expert with Karen Sepko and Associates. Thank you, Brenda. And I would like to welcome everyone to this evening's presentation, where we will be doing a focused overview of ICD-10 fracture coding related to the hand surgery specialty. My file here is, and you can take a look at it as we go through the slides. I do have a disclosure to make, and that is I am an employee of Karen Sepko and Associates, and I am also a consultant and advisor to Modernizing Medicine. On our next slide, just an attention, sort of disclosure again, that no part of this webinar, including any slides or handout material, may be copied, modified, reused, distributed, or otherwise reproduced in part or in entirety without the express written consent of Karen Sepko and Associates. On slide five, if you were able to download, and if you would like to follow along, for the most part, your presentation will go slide by slide. We did do some last minute changes, and unfortunately the final PDF did not get loaded. So you will have some additional slides in your packet that I will be presenting with this evening. But for the most part, there will be an exact one-to-one match, and you should be able to follow along by slide number. So on slide five is our agenda. And for today, tonight's course, I'm not planning on going through the very basic introductory rules of differences related to ICD-10. The discussions about ICD-10 have been going on for some time, and for the most part, you've probably heard some of the basic differences between ICD-9 and ICD-10. We will begin, though, with a basic compare and contrast of the similarities and differences as it relates to fractures, though, the topic of our webinar. And then we hope to dive into the building up or tearing down, whichever way you want to look at, the ICD format to better help you understand how to select fracture codes. Documentation is the key. Again, I'm not going to specifically point out documentation tips one, two, and three, but as you, the provider, are listening to this presentation, it will be key and critical for you to make note of documentation requirements that you may have to make change or you may have to do tune-ups in your own dictation to ensure that the information that will be required to select ICD-10 codes based on the new documentation system and the requirements related to specificity, the type of fractures, such as transverse, segmental, open, type 1, type 3s, type 3Bs, type 3Cs, and the specific anatomic location on the fractures. That will be the takeaway that we hope you have in terms of documentation requirements in ICD-10. So when we talk about comparing and contrasting ICD-10 to ICD-9, essentially today we're looking at the layout in the book and we're looking at the format of codes, and that's the compare and contrast that we are going to do this evening. So what's the same as we talk about the layout? Well, the alphabetic index is the same. So as in ICD-9, ICD-10 contains index to diseases and injuries, and it also includes the neoplasm table, table of drugs and chemicals, and the index to external causes. All of that was in nine, it's all in 10. The tabular list is both in nine and 10. There's a list of alphanumeric codes divided into chapters based on condition and or system, and while the tabular lists are the same, what changes is the codes, and the codes are organized now alphanumeric, so they're not essentially just alpha or beginning with the numeric code E and V that we've used in ICD-9, and the tabular list contains categories, subcategories, and valid codes, and we're going to talk in detail about categories, subcategories, and valid codes as it relates to fracture coding this evening. What's the difference and what is difference when you're looking at the ICD-9 and you look at the, or between ICD-9 and ICD-10? As I've given you here a screenshot and I've sort of excerpted out the chapters that are significantly important to you as we talk about fracture coding and musculoskeletal coding. So you will see here in chapter, in ICD-10, we have chapter 13, which is Diseases of the Musculoskeletal System and the Connective Tissue. These are found in the M chapter of, in chapter 13, these are found in the M category within that chapter. In ICD-9, we also had Diseases of the Musculoskeletal System and Connective Tissue, and these were found in the 700 codes that you are very familiar with in terms of reporting services for today. So chapter 13 in ICD-9 is the same as chapter 13 in ICD-10. Moving then down to chapter 19 in ICD-10, we have the Injury, Poisoning, and Certain Other Consequences of External Causes, and this is found in chapter 19, and the categories will be the F00 to the T88 codes. That compares to chapter 17 in ICD-9, the Injury and Poisoning chapter, which were the 800 and the 900 codes that we used when you had patients who came in with traumatic injuries, such as fractures, sprains, strains, ligament injuries, open wounds, those were found in that chapter. Tonight we're going to focus on fractures that are found primarily in chapter nine, and then at the end I will talk about, in chapter 19, I'm sorry, and then at the end I will also just compare pathologic fractures that are found in chapter 13, and that will be our goal for this evening as we look at the formatting and the layout of ICD-10. When we look next at the format change, we have layouts in the book, and then we have format and structure changes in ICD, between ICD-9 and ICD-10, and this is where you heard, and you've probably seen the diagram here showing the differences from the three to five digit codes in ICD-9 to the three to seven characters in ICD-10. So when we talk about coding ICD-10 in orthopedics, there are two very basic concepts that will make this easier as you get started. In ICD-9, when you coded procedures from the musculoskeletal section, such as codes that were for chronic conditions, your osteoarthritis, for example, you used codes in the 700 section. That will automatically correspond, that first digit of a seven for your osteoarthritis in ICD-9 will correspond to an M code in ICD-10. So ICD-9 codes that began in the 700 series will automatically map over to codes in the M section in ICD-10. Your injuries that were always the first digit of an eight in ICD-9 will always be an S code as the first alpha character in ICD-10. And if we can use this to build on the concept of how the codes are created, this will be helpful. In ICD-9, you see that you had categories, the first three digits, and then the etiology, anatomic size, and the severity. In ICD-10, we also have the category being the first three characters. Then we have the next three characters after the decimal point that become the etiology, anatomic site, severity. And then the concept of an extension becomes new to us in ICD-10. And we will talk more about that as we move forward this evening. When we further break down chapter 19 on the next slide, which is slide 10, we see that chapter 19 is broken down into coding of injuries and fractures. And again, these will be codes that begin with the alpha character of S. And then ICD-9 was an 800 character. And then there are also in chapter 19, there are T codes. And T codes will be used to report early complications of trauma and mechanical complications. Those T codes corresponded in ICD-9 to the 900 codes. Tonight, we want to focus here on the S codes as it relates to your fractures. So what makes up an ICD-10 code? So if we look here at the slide 11, and you see the arrow sort of building up, this is what makes our ICD-10 code. So codes, again, have characters that the category of the code will be the first three characters. So if we look here at the diagram, the category S52 defines fracture of the arm. And I'll come back to tell you how we know that this is a fracture of the arm category code. In order to code fractures, there has to be a seventh character. So all fractures, we have to make them seven characters if they are acute traumatic injuries. Anything less than seven characters would be kicked out as denied or an invalid code when submitted to the payer. So codes can be anywhere from three characters to seven characters. The first three are always going to be found in the category section. And then we create what becomes subcategories that can be four, five, six, or seven characters. Three-character codes essentially do not exist in orthopedics or hand surgery. Fourth-character codes, so just having a code with four characters, is rare in hand or orthopedic coding. And it's rare because we have to deal with issues such as laterality. So it will be very common that we're going to have when we have conditions that have laterality and that occur bilaterally, that we will be dealing with a minimum of potentially five characters to the majority of our diagnosis codes. So let's take a look at the algorithm here. First we have for this fracture, we have the category is F52, which is a fracture of the arm. Then it is divided into a subcategory. And if we were to look at F52, we would see a check the fifth before F52.0. Same concept in ICD-9 when it told us that we needed a fourth or a fifth digit, we will see a check the fifth, sixth, or seventh as appropriate as we further subdivide our subcategory. So F52 is the category. A subcategory here is F52.0. It tells us to check the fifth, which means that we need another character. And F52.0 now defines a fracture of the upper end of the ulna. This requires a fifth character. So when we look at the fifth category, and this is subdividing further, that subcategory is further divided, it now tells us that we need a sixth character. And F52.01 is a torus fracture of the upper end of the ulna. So we have now gotten specific into the type of fracture. We've got the anatomic location. We've now gotten specific in terms of the type of fracture. So it's a torus fracture of the upper end. When we look in the ICD-10 book, it now tells us we need a sixth character. The sixth character is further subdivided into laterality. Torus fracture of the right ulna, and this is the upper end of the ulna. And we see it now goes to F52.01. We would like to say that this digit here, this character here of one that I am pointing to, with always right, it's pretty much consistent. Within orthopedics, that right will always be one, and it will always be the last character. But that's not always true, because we will see in fractures, as you go out to the seventh digit, we now have the letter A that is preceded by the one. So the one tells us it's on the right ulna, and the A tells us it is the initial encounter. This is a fracture code. A fracture code has to have seven characters. And this code has now been based on your documentation position. You have now given us enough information to tell us that it's on the upper end of the ulna, it's a torus fracture, it's on the right extremity, and we know that this is the initial encounter. So we have enough information to have created a code, and this would be the code that we would report for the initial encounter for a torus fracture of the right ulna. Now we're going to further tear this down as we go through the sessions this evening. So our next chapter then that we wanna talk about is chapter 19 again. As I told you, there's the S00 to the T98 codes, our injuries, our mechanical complications. We're going to focus again on fractures. So on our slide 13 that is showing on the screen today, we've got some basic guidelines for coding injuries. The first bullet here says that a fracture not indicated whether displaced or not displaced should be coded to displaced. This is the only place I believe in ICD-10 where you actually get to code to a higher level of specificity if you don't tell us the fracture is displaced or not. So if you do not tell us and you do not document that the fracture is displaced or not displaced, it ends up being coded as a displaced fracture. The second bullet here tells us that a fracture not indicated as open or closed should be coded to closed. Obviously when you're documenting and you're dictating your diagnosis, pre-post-op diagnosis, it would be to our benefit for you to tell us that the fracture is open or closed and whether it is displaced or not as that is going to help lead us in building up the correct information to choose the correct code. Non-traumatic fractures such as your osteoporotic fractures, such as your stress fractures, your pathologic fractures are not coded in the F section, they are coded in the M section. So the third bullet here tells us to report a non-traumatic fracture with the code M80.something, zero on out for any patient with a known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if and only if that fall or trauma would not usually break a normal healthy bone. So that's sort of a quirk in our injury coding services. And then the last bullet says here that the aftercare Z codes should not be used for aftercare for traumatic fractures. For aftercare of a traumatic fracture, we are going to assign the traditional acute fracture code just as we sort of built in the last scenario, but the seventh character, which we haven't really talked about yet, is going to change. So Z codes that you have used potentially for aftercare of fracture codes go away and we continue to report the fracture code, but the seventh character of that fracture changes. Our next slide here shows our hand anatomy for documentation not for education for the physician's component, but for staff's purposes, this is important. And this will be important as the physicians are documenting the anatomic location of the fractures or for any of the injuries in the hand or in the wrist as we move forward. So you see here we've color coded for you the anatomy of the hand. So the phalanxes, all of the phalanges, are color coded yellow and we have a line drawing across the distal phalange from the little all the way to the thumb. The middle phalanx, or in ICD-10 you will see this called the medial phalange, is drawn, the line goes from the little to the index finger with no middle phalange noted in the thumb and the proximal phalange from the little over to the thumb. So again, it's gonna be important that we have which finger and we have the anatomic location which bone is fractured or injured. The metacarpals are indicated here in purple and notice here for the thumb, the metacarpal, the first metacarpal starts here in the thumb, the second is the index, the third is the middle, the ring is the fourth, and the little finger is the fifth metacarpal. Again, this is important because as you report diagnosis codes for the metatarsals, or metacarpals, sorry, we're gonna have to know the specific bone and we're also going to have to know the anatomic location on the bone such as the base, the shaft, or the neck. Then broken down further into the blue are the carpal bones and then you see here the navicular is broken down into the distal pole, the middle third, and the proximal third of the navicular. This information will have to be documented in order to choose the correct diagnosis code for the fracture of the carpal bones specifically in the navicular here. So again, we're gonna go into a little bit more as we continue to go forward. When we take a look at the next slide here, the team put together a hand and wrist documentation tip. So we've broken out the carpal bones, the tracheotum, or the cuneiform, the lunator, the semilunar, capitate, or the sphagnum on through and broke down the specific bones where we have specific diagnosis codes in ICD-10. For the first metacarpal fracture, we've got the bennets, the rolandos, other base, the shaft, and the neck. For the other metacarpals, other than the first, but we are going to have to know for the second through the fifth, the base, the shaft, the neck. For the thumb, as I mentioned, you have the proximal and the distal phalanx. And then the fingers will see the proximal, the medial, and the distal phalanx. In addition to all of these, we need to know whether it's on the right hand or the left, whether it's displaced, non-displaced, open, or closed. So that information will have to be available for you to accurately select your diagnosis code. Now, because this all can't be quite as easy and because there's really no correlation between CPT and ICD-10, in CPT, we have the F modifiers. F-A to F-4 are your modifiers on the left hand for each finger. And on the right hand, we have F-5 through F-9. Well, in ICD-10, the fingers, the thumb and the fingers are numbered, one, two, three, four, five. And so it could potentially become confusing when we're coding between the two systems. So we're gonna have to make sure that we're accurately recording our CPT code to match up with the correct diagnosis code for the correct extremity as you are coding. So again, just a little confusing potential there. We want you to make sure that we pay attention to that as we go forward. On the next slide here, I'm introducing you to a creation of KCA, who is our injury guy. And our injury guy becomes very useful to you as you are coding your fractures. And we're hoping that it will easily identify and ingrain for you the appropriate F code based on the anatomic location and the type of the injury. So remember here that we have to know the category and the category of the first three alphanumeric codes. When you meet the injury guy here, you will see here that based on the anatomy, we have put the appropriate injury code. So S00 defines an injury to the head. The zero is head. S10, the one, is to the neck. The S40 goes to the shoulders. S50 goes to the elbow radius and ulna. S60 goes to the wrist, the hand, and the fingers. And obviously the same numbers correspond on the bilateral side, the contralateral side of the body. I'm not addressing the rest of the injury guy here. We're going to be focused here in the hand, wrist, fingers, and the elbow radius and ulna. For those of you who extend up into the shoulder, you obviously will go back up into the S40. So when we look at the first three characters, the alphanumeric character, the first character for an injury will always be an S. So as we're looking in the ICD-10 book, we're automatically gonna go to chapter 19 and we're gonna look for the S code. The second character is going to be the anatomic location. In ICD-10, I'm sorry, ICD-10 uses numbers from zero to nine. So as you look here, zero is head, one is neck, two is thorax, three is spine, seven is hip, eight is the knee, tibia, and fibula, and nine is the ankle. So ICD-10 can only use the numbers zero through nine because if they tried to use 10, it would upset the apple cart in terms of the ability to have only seven characters. So that's our anatomic location. So the third character of the three category codes is going to be the type of injury. So we're going to build on this and we're gonna build some ICD-10 codes as part of your introduction. So first code is the category, is for injuries. Second character is for the anatomic location, zero through nine, and obviously you're going to be interested in the anatomic location, the character of five and six, which is a numeric code, and then the type of injury will be the next. So if we further break this down and we're building on the code, so S is our injury. The second character here is going to be our anatomic location, and again, head, neck, thorax, lower abdomen, shoulder, elbow, wrist. Again, five and six. So your code begins S5, S, S5, or S6 is going to give us the anatomic location. Injuries are grouped by body part in the block. We're gonna use this to build where we're going. The third category is the type of injury. So on this slide, you will see the type of injury. You have an S, you have an S with an at zero, which is a superficial injury. You have an S, and this is the S is for the anatomic location with a one, which is an open wound. S at two is a fracture. So all fractures are going to be S52 or S62 for your fractures from the elbow to the fingers. So automatically, you're going to hone in, in ICD-10, in the chapter 13 numerical code, you're going to be looking at the category S52 and S62 to take you to your fractures. You'll also look at S51 for your open wounds. You're gonna look at S53 or S56. Three is for dislocation, subluxation, sprains of the joints or ligaments. The four is gonna be for nerve injuries. Five is for vessel injuries. Six is for muscle or tendon injuries. Seven is crush injuries. Eight is amputations. And then nine is other and unspecified. And we will try to avoid the other and unspecified as much as we can, but there may be situations such as physio fractures under the Salter-Harris classification that we may have to use an unspecified code. So when we're looking at the anatomy of the ICD-10, the first three characters of the seven-character code tell us the S is an injury. The second character is going to tell us the anatomic location, six or five. And then the third character, the R here, is going to tell us the type of injury. So with that in mind, let's do a little test. And we'll do this together. And my answers didn't fall in, so you'll see the answers here. So I have here the amputation, complete, small finger of the left hand. So if you go back to your injury coding guide and you go to the anatomic second category, the wrist, hand, and fingers is category six. And if you look at injury guide, the third character, amputation, falls in the eight. So S68 are gonna be amputations involving the hand and the fingers. Dislocation of the right elbow, again, it's an injury code, S. Elbow is five, dislocation is three. Crush injury of the left hand, injury is S. Six is the hand, seven is crush injury. So these are our first three codes in building our seven character code. And these all define the character in ICD-10 that we will go to. A laceration of the right index finger is going to take us to S61, one being the laceration. A splinter in the thumb will take us to S60. Moving on, a near classification fracture of the right proximal humerus. Humerus is found in, it's an injury. The anatomic location is four. It's a fracture, so it's two. And all of the remainder of these are fractures. The olecranon, torus fracture of the distal radius, buccal fracture of the radius, buccal of the ulna, all belong to category five, which is our injuries of the elbow and the forearm. Your distal radius fractures do not code to the injuries to the wrist and the hand. They code to the five section, not to the six for the wrist and the hand. So that gets us through our category. That gets us through the first three codes required for capturing the category for reporting fractures. So the next concept that I want to talk about, which is on slide 22, is the seven character extension. And this is sort of where everybody has sort of been in the ramble and the mumbling and the confusion in terms of the extension code and exactly how that is used. So this is a big part of orthopedics. And as we move from the three character in the category, the next three are gonna be etiology, anatomic site, and severity. The last character is the extension code. Remember that all injuries, all traumatic injuries, all traumatic fractures have to have a seventh character requirement. And the seventh character changes and is not exactly the same for every code. So we want to talk a little bit tonight just about the seventh character extensions. So on slide 23, the seventh character extension, and in your PDF this may be a little bit further down toward the Leo C. Thar graphic. But the seventh character extension helps us understand where the patient is in their healing status of that fracture. And we talk about initial versus subsequent encounters. Traumatic fractures are coded using the appropriate seventh character code for the initial encounter, A, B, or C, when the patient is receiving active treatment for the fracture. And active treatment for the fracture is always going to be our initial counter. So the initial encounter, and we will go through some examples to help you understand what is the initial encounter. What we have to make sure that we do is that we do not confuse initial encounter for diagnosis coding with an initial patient visit in CPT. They are not the same thing. So an initial visit in CPT is a new patient visit. An initial encounter can be used for multiple episodes of care because we use the initial encounter while the patient is receiving active treatment for the fracture. The appropriate seventh character code for the initial encounter should be assigned for a patient who is seeking delayed treatment for the fracture or non-union. Again, it is your initial encounter if that patient has not been seen before and they come in and they have delayed treatment, we use the initial encounter form for the initial management of that patient. Fractures are coded using the appropriate seventh character for subsequent care for encounters after the patient has completed active treatment of a fracture and is receiving routine care. And I'm gonna go through several different scenarios of the breakdown for the fracture as we move through tonight's presentation. Care of complications of fractures such as malunion and non-union should be reported with a seventh character code. So we don't look for non-union or malunion codes anymore. We continue to use the acute fracture code and what changes is the seventh character. And again, we will go through some examples so that we can see how this looks. So let's take a look at the seventh character extension. And on your slide 24 right now, what you should have in front of you is the slide that says most categories in injury chapter 19 have a seventh character requirement. And then most injuries, with the exception of fractures, have three seventh character options. So if you have a patient who comes in with an open wound or a sprain or a strain, you may only have to assign an option of an initial encounter, the subsequent encounter, or a sequela. So if we look at subcategories, the categories S50 and S51, superficial injury of the elbow and the forearm, and an open wound of the elbow and the forearm, we only have three options for the seventh character. The first is the initial encounter. That's the code that we're going to use during the initial active treatment phase of the patient's care. The D is going to be a subsequent encounter for routine healers. And S is going to be a sequela. And a sequela is what you used to call a late effect. It is now called a sequela. So non-traumatic fractures are going to be covered from chapter 13, have a seventh character, but typically they do not have the same extent of a traumatic fracture because we're not as concerned about all of the stages of healing. Your traumatic fractures, your injuries, dislocations, sprains, strains, open wounds, are all going to code to the seventh, but the range of the seventh can be from three different characters as you see here, up to a range of as many as 16 options for the seventh character, depending on where the patient is in the phase of healing. So let's go back to the active treatment because that one is going to be one of the main questions that everybody has. So what does active treatment, what does the initial encounter mean? The initial encounter, or the seventh character of an A, is used while the patient is receiving active treatment. Examples of active treatment could be taking the patient to surgery, could be your first encounter in the ER, and it is important to understand that the initial encounter is reported with an A for each new evaluation and treatment by a new physician. And again, this has nothing to do with CPT coding of a new and established patient. So I've got a couple of scenarios here. If you see in your workbook, you've got a couple of scenarios of the seventh character, and we're looking now at the A for initial, the D for subsequent, and the S for sequela. So let's take a look at the first of the initial encounter using the character A. So Mr. Bryant is seen by the ER physician for a closed, displaced both bone forearm fracture. The ER physician reports his or her appropriate service and uses the character A because it is their initial encounter. The patient is in the initial active phase of treatment. It's the initial evaluation. Dr. Hand goes to the ER because he's called in in consultation for evaluation of the displaced closed both bone forearm fracture. And Dr. Hand is a new physician performing the evaluation of the patient, and this remains an initial encounter for Dr. Hand because the patient is in the active phase of treatment. The next scenario, Mr. Bryant is taken by Dr. Hand to the OR for an open reduction of a both bone forearm fracture, and Dr. Hand now reports again for his surgical case or her surgical case, the ORAF with the seventh character of an A for the both bone forearm fracture because the patient is still receiving active treatment of the fracture. So from the time the patient originally is seen until the time the patient is treated for that fracture, all interventions by any provider, the radiologist, the consulting physician who might have to do a pre-op HMP, all of those physicians are going to be reporting the same fracture code with the same seventh character of an A because the patient is receiving active treatment of that fracture. Now, let's take a look at the D. So the D, which is our other option here, and it's a subsequent encounter if you went back to the previous slide, the D is the healing phase. So for the case of our injuries, the subsequent encounter is used following active care when the treatment, when the patient is receiving routine care for the condition during the healing or the recovery phase. So if a patient comes in for a cast change or suture removal, comes in for their normal post-op visit, you're adjusting their medication, you're seeing them in response to occupational therapy, if they're in the normal routine healing, then the seventh character now switches from an A because they're no longer receiving active treatment, you're now seeing them for their essential post-op follow-up care and everything is healing well. So we now report the D. And here's some examples. Mr. Bryant has seen one week post-op by the PA in the office. Normal healing, no problems. The PA reports into the practice management system. We will use the acute fracture diagnosis code, but now the seventh character is changed from an A to a D. Example number five. Mr. Bryant has seen for suture removal post-op by Dr. Han. We now are also going to use a D because the patient is being seen for routine healing. And then the last example, Mr. Bryant is seen during the post-op period by the cast tech to put on a new cast in the office. It's still a D because it's subsequent care, routine healing. If a partner sees the patient, it's the exact same. Routine healing, the physician records into the practice management system the same acute fracture code, but now uses the seventh character of the D. So that's initial care. That's the subsequent care. Now let's take a look at the third extension in this grouping, and that's the sequela. So the sequela, the S extension, is used for complications or conditions that arise as a direct result of a condition or injury, such as scar formation after a burn or contracture after a fracture, non-uncommon in hand surgery. The contracture is a sequela. We used, in the old days, we called those late effects, and we coded those as a late effect. And now we call them a sequela. Malunion, nonunion, delayed unions all have their own seventh character extension. We're going to show that in one of the upcoming different options of seventh character codes. They have their own extension, depending on whether the fracture is open, closed, whether it's a delayed healing, whether it's a sequela, and then nonunion, nonunion, all have their own code. If you have a patient who presents with a sequela, you will code both the sequela and the injury code. So in ICD-9, we just coded the 905.2, late effect of a fracture, and then we coded whatever the late effect was. In ICD-9, we will also use the code for the late effect, and then we will have the S52.XXX, and then the seventh character becomes the S for sequela. So we again are tracking this patient through their course of care related to this fracture, and this gives our morbidity mortality for the purposes of tracking disease outcomes, if you will. We're tracking the patient through the phases. The next slide here gives us an example of different seventh characters, and so I just put in some slides here to give you some options of the seventh character extensions and how they are used. So in this slide 34 here, you see a torus fracture on the upper end of the ulna, check six, 52.01, tells us the seventh character is required, so obviously there's going to have to do laterality here. The seventh character now, we have the A for the initial encounter for a closed fracture. Then we have four subsequent encounter codes. There's a subsequent encounter for routine healing, which is D, subsequent encounter for delayed healing, which is G, a K is a nonunion, a P is a malunion, and then we again see the sequela. These instructions of which range of seventh character codes are applicable to a category or subcategory are found specifically within the body of the ICD-10 book, so it's important that you mark your books, tab your books to the F50s, F60s, and you understand where the range of seventh character codes apply within that range. This is a green stick fracture of the shaft of the ulna. So same thing, it's a check the six, we have to have laterality here, and then we have the same series of six different seventh character codes, just as in the torus fracture, the same series of seventh character codes apply. If we take now a look at the slide 36, F62, and this will be in your new handout, F62 is a fracture of the wrist and the hand level. This includes the carpal, the metacarpal, and finger fractures. We now have seven possible characters, seventh character codes that can be used, and you will notice here what has changed is that A is for the initial encounter for a closed, and we now have a B for the initial encounter for an open fracture, and then we still have D, G for the routine and delay, K and P for our nonunion malunions, and then we have S for the sequela. Remember that the fractures have to have a seventh character, so this F62 gives us the first three or the category, and then we're gonna have to know the specific anatomic location, the type of fracture, the laterality, and then obviously the encounter to build the code. So this is what it looks like in your ICD-10 book. So what I've done here on the next three slides, essentially I've just created three slides that if I were to go to this section of the ICD-10 book, this is what you would find. So F52 is a fracture of the form. We see notes here of the fracture not displaced, not indicated as displaced or non is going to be coded to a displaced. We already talked about that rule. That's found throughout the entire section of the ICD-10. Also talks about the open or closed should be coded to closed, and then it also now talks here about the open fracture designations are based on the gastilla open fracture classification. So we're gonna talk about that classification system and the numerous, what we call the alphabet soup of the seven character extensions where we go up to the potential of having 16 different seven character extensions. I want to, while we're on this slide, just talk briefly here about the excludes one and the excludes two notes because these are very important notes in ICD-10. Excludes one means you can never report, this category of code, traumatic amputation of the forearm, F58, can never be reported with an F52, and it's obvious. If the patient has a traumatic amputation of the forearm, we can't always also code for a fracture of the forearm on the same arm that has a traumatic amputation. So an exclude one means you can never report the two categories of codes together. The excludes two means that it is possible that you could report a fracture of the forearm and a fracture at the wrist and the hand level. So we could have a fracture of the forearm, radial shaft, and you could also have a metacarpal fracture. So we would have a code from the F52 category and we would have a code for the F62 for the metacarpal fracture. So excludes one, never can be reported together. Excludes two, it is possible, assuming the documentation and the pathology is there. So that's the beginning of the F52. Then now when you open up and further read down into the listing of the seven character extensions, we now see the alphabet soup and they're broken into two slides here, but you're gonna see one concise slide coming up and this is literally a copy and paste from the ICD-10 book. So we now have the initial encounter for a closed. We have an initial encounter for an open fracture type one or an initial encounter for a fracture not otherwise specified. And then we have an initial encounter for an open fracture type 3A, 3B, or 3C. So for the docs, you can see where your documentation is going to have to become more comprehensive if you are not currently including this type of information. We next, we now move from the Ds on down here on this slide, we move into subsequent encounters. We have a subsequent encounter for a closed fracture with routine healing. And then we also have two codes, E and F, for a routine healing of a type one or a routine healing of a type 3A, 3B, or 3C. Case fracture code stays the same. The seventh character code changes based on the type of fracture and whether it's routine healing. G and H, delayed healing for a closed. H is open fracture type one with delayed healing. And then we move on to the subsequent encounter for an open fracture type 3A, B, C with delayed. The K and N are nonunion. The P, Q, R are valunions for the closed and then the two open. And then a sequela. So we have the potential for 16 different characters here. Your documentation is going to be critical to make sure that we choose the correct seventh character code. So here it is a little bit more concise. So I'll put it all in one bracket here. Again, you see the A, B, and C are the initial encounters, closed fracture, and then the two different opens. D, E, and F are subsequent encounters, routine healing. G, H, and J, subsequent encounters, closed and open fractures, delayed healing. You, the surgeon, decide if it's routine, it's delayed, if it's delayed or a nonunion or valunion. So we have bracketed these here for you as a simpler way of taking a look. So let's take a look now at this 16-character alphabet soup and let's look at how this affects the fracture code. So here is the code, S52.22, and I put one and then I have a need for the seventh character. So S52.2 is a fracture of the shaft of the ulna. You can see I've put them in blue. This is the category and the initial subcategory division. S52.2, fracture of the shaft of the ulna. The next code is in, the two is in green, and that is a displaced transverse. So now we need to know the type of fracture and it's displaced. We code displaced, not displaced the same, the seventh character tells us the difference, tells us what's happening in terms of the encounter. The one here tells me it's the right, so now I know that we have a displaced fracture of the shaft of the right ulna, so I have the sixth character. Now I need to fill in the bracket for the seventh character. So this is our distilled fracture classification system. This ties back to the grid that's concise on the previous page. A, D, G, K, P are all closed fractures. The brackets here, E and C, E and F, H and J, M and N, Q and R are open fractures and again, initial encounter, routine healing, delayed healing, nonunion, malunion. This is the information that we will use to create the appropriate seventh character for this traumatic fracture, displaced transverse fracture of the shaft of the ulna, A, initial encounter, B, subsequent, I'm sorry, D, E and F are subsequent, G, H and I again, or G, H and J, delayed. So we're looking for your documentation to help us fill out what's this seventh character. In ICD-9, the A here, the closed fracture, which would be S52.221A, corresponds to 813.22 for the fracture of the ulna alone. B and C, the S52.221B are S52.221A, S52.221C in ICD-10 correspond to 813.32, which is an open fracture of the ulna alone in ICD-9. So in ICD-9, we had one code for the closed, one code for the open, and now we have the potential for three different codes based on the type of fracture that is being reported and treated at this time. When we look at our traumatic shaft fractures, again, your documentation needs to tell us if it's a green stick, transverse, oblique, viral, comminuted and segmental, and each of these fractures has different categories. So for your shaft fractures of the ulna, S52.31 is a green stick, S52.32 is a transverse, S52.33 is an oblique, S52.34 is a spiraled, S52.35 is comminuted, and S52.36 is segmental. So the fifth character changes based on the type of traumatic shaft fracture. Again, it further subdivides the codes to give us more accurate information. So we're saying, okay, makes sense, how do we make this easier? And this is where we introduce Leo C. Farr. And Leo C. Farr was the brainchild of Margaret Mailey from Karen Zupko and Associates, and Leo was actually born out of Codex. So when we look at the acronym here, laterality, we're looking for right and left, we're looking for the name of the bone plus the exact location. Proximal, distal, upper end, lower end, medial, coronoid process, we need the exact location of the bone. The E is the encounter, is it the initial, is it subsequent, is it routine healing, is it delayed, nonunion, malunion? Open or closed is obviously easy. The category or classification, is it traumatic, is it fastillo, are we gonna code under the Salter-Harris, the near, or the zones, depending on the type of fracture. For the fracture pattern, is it transverse, oblique, spiral, segmental, just as we looked at? The alignment, displaced versus nondisplaced, and then the results. Is it routine healing, delayed, nonunion, or malunion? And so Leo C. Farr can actually help us further define the category of code. Codex makes that easy for us, and this is a good way to go in and automate Leo C. Farr. So you can see here, you've got a dropdown menu for the body system, so you can put in the arm, the wrist, the hand, you can put in laterality, the encounter, the category, open, closed, the result, the pattern, and the alignment. It is a lot of fun to go in and have this start out blanket, 69,000, and narrow it down to two or three codes. You can easily do this with the dropdown menu in Codex. For those of you who have Codex, if you don't have it, we'd recommend that you get it, because it truly will help us easily get to our fractures. There's one electronic health record system that I have looked at, and as I was doing some ICD-10 education in December, and I was going through the Leo C. Farr with clients, and helping them understand how to use this, they found this to be very easy, and we got to the fracture code very quickly. They went through their electronic health system, health record system, that had their ICD code built in also, and as we were doing the similar search, they were getting searches of 50,000, 20,000, 30,000, 15,000, and they couldn't get it to hone down as quickly, because the EHR system was searching the universe of terms versus the PICLIS that has been created in orthopedics, and as you know, those of you who are users of Codex, we now have PICLIS for fractures, arthritis, spine, and osteomyelitis, to help us get to the code quicker. The next slide, then, is, again, your castillo classifications. On the left-hand side, I've given you your castillo, well, it says your open fracture classification, your type 1 through type 3C, and then the mirror image of the traumatic fracture for closed or open with the castillo classification. That's our 16-code range, or alphabet soup. So, again, a resource for you in terms of what your documentation has to include for your open fractures of your long bones. We need to have this information documented. So, now we have classified guide. You've met injury guide, you've met LEOC-BAR, you've met, now you get in the classified guide, and what has happened here is that we have highlighted in yellow for you where the castillo classification applies which long bones are used, applicable in ICD-10, to be reported using the castillo classification system. So, again, a resource for you to make this easier. The Salter-Harris classification of thiazideal fractures. There are nine types of Salter-Harris fractures. The vast majority of these will be found in categories one through four. You're going to see on our next slide how we code the five through nine in ICD-10. There's no open codes for thiazideal fractures in ICD-10. Doesn't mean that you can't have an open fracture. It just means that you would have to code the appropriate Salter-Harris fracture and then you would have to code an associated open fracture code, open wound code, with your Salter-Harris fractures. Type five through type nine are uncommon and do not have specific ICD codes, and so we're gonna have to use them with the others specified which I mentioned early on in the presentation when we were looking at the injury guide and the classification of the fractures. Next slide here just gives us the Salter-Harris fracture of the distal radius, and we can see that this is a type one is going through the growth plate. It transfers through the growth plate. We also have our classified guide, and we can see here the anatomic location. So S49 is going to be the humerus, S59 the proximal ulnar distal, and the radius. The S49 is gonna be our Salter classifications one through four. Your proximal ulna is gonna be other, your distal ulna and your radius will be in the one through four Salter classification. Salter-Harris fractures are found at the end of each corresponding body area. And again, these are highlighted for you in purple. The next gives us a screenshot of a codex, and this is using the ICD-10 search by code, and I just typed in Salter-Harris, and you can see here it has given us the codes. You will see that there are no open fractures. Everything is an initial encounter for the closed, initial encounter for the closed. So there are no open fractures, but you again can see all the seven character codes as appropriate here for the Salter-Harris, and this is how codex can be helpful to us. The next slide here, I just wanted to put in elbow anatomy, and you can see here the specificity of what is gonna have to be documented in terms of the exact location of the fractures, the exact bones, to make sure that we are coding correctly. The elbow expanded documentation tips, right and left obviously have to be documented, displaced versus not, open versus closed. And then we must note that in all of ICD-10, the radius and ulna fractures are reported separately. There are no combination codes. There are no both bones forearm fractures. You have to code both the radius and the ulna separately if you have a both bone forearm fracture. The next slide here, I've just given you some tips here in terms of the anatomic location and the appropriate categories of codes that they're gonna fall through based on their anatomic location and what needs to be documented. So you have your simple and your comminuted supracondylar with or without interarticular extension. You've got your transcondylar, there's your torus fractures, your olecranon, again with or without interarticular extension. Delayed union and non-union, you can take a look and read at this, but essentially there is no consensus and it comes down to you, the surgeon, to determine whether or not the fracture you are treating is a delayed and a non-union. Obviously there are gonna be some criteria to determine this, radiographic, symptomatic, time passing without signs of healing, but the timeframe when a fracture is called a delayed or non-union is gonna vary based on the bone and the clinical judgment of the practitioner. And then we don't, we code these with the seventh character of, as we've seen in the alphabet soup, these are not coded as complications. When we talk about pathologic fractures here, we're now out of chapter 19 and we're into chapter 13. And these are gonna be our stress fractures, our neoplastic, our osteoporotic fractures. These go into the M category. If we take a look at the M, chapter 12, the M category, we've got M80 is osteoporosis with current pathologic fracture. M81 are gonna be the osteoporosis without current pathologic fracture, so obviously the documentation is going to need to include this. And then the M84 category are going to be the disorders of continuity of bone when your stress fracture is pathologic, fractures in neoplastic disease and other disease fall, differentiating between traumatic and pathologic. Pathologic fracture documentation tips, site and laterality need to be included as part of the anatomic location. The etiology to correspond to the correct category. And then the seven character extensions here, initial, then we have our subsequent for routine, delayed, nonunion, malunion, and sequela. If a patient has a pathologic fracture that is open, you'll have to code the open wound code in addition to the pathologic fracture as there is no specific character for an open fracture. Again, a search in ICD-10, I just typed in pathologic fracture of the radius and you can see here it took me to the appropriate M84 in terms of the various different encounters, A through your S's, codex can be very useful. External causes, do we need them? We don't need them unless you need them today. So we're not gonna make you know that they were bit by an orca or hit by an orca or crushed by an orca unless your payer requires it today. So I've given you in the handout a source document upon the American Health Information Association related to external causes and this has been countered by Medicare and both the AHIMA statement and Medicare say that unless external causes were required by your payer in ICD-9, you don't need to use them in ICD-10. If they were required in nine, then they will probably be required in 10. But we don't need to know that we were snowboarding, water skiing, fell off the ladder, hit our finger with a nail, put the nail through it, crushed with a hammer, hit by machinery, all of that is not going to be necessary in ICD-10 if it was not required in ICD-9. 12 steps to get your practice in gear, pretty standard in terms of what you've been hearing. We wanna run an ICD-9 frequency report and I'm gonna show you a sample report that I've run from some clients. We wanna look at these because we wanna start working on your operative notes, we wanna pull your reports for your five top diagnosis codes probably weekly and we wanna start closing any gaps in documentation. We want you to begin coding them in both diagnosis coding systems. I was speaking with a client recently where their hospitals are gonna start them having to code in ICD-10 beginning next month. So they have to be up and ready to go because they're gonna have to get the hospital system, both ICD-9 and ICD-10 systems. Check what your software vendor has to offer in terms of resources and support, figure out that this whole transition is gonna cost, what it's gonna cost your practice. There are a lot of costs in terms of education and resources that go with this. Investigate your medical necessity guidelines for your top five diagnosis for your three payers. This will be important in terms of your trigger point, your carpal tunnel injections, those type of pen and sheets injections, those that currently have LCDs or medical policies from your payers. We're gonna have to know how those apply in ICD-10. First availability, run some tests with your software. We should be doing that now. Medicare is testing currently. Want you to take advantage of Codex, sharpen your practice collection skills, determine if you're gonna need a line of credit, which we are recommending. You should probably have that on board now. It's easier to get money when you don't need it than when you do. There are expectations that claims will be denied and payments will be delayed beginning in October 2014. Begin monitoring your payer websites for, again, the medical policy. So this is a sample ICD-10 report that I ran for eight different hand surgeons from clients of mine across the country. Some of these were academic practices, some of these were solo, some of these were group practices. And what I did is they shared with me their ICD-9 report for each of the surgeons and I sorted these for the fractures. So I took out everything else because all I wanted to focus on was the fractures. So if we're looking at this and you can see here what their top diagnosis codes across the board were, 813.42, 816.0, 815.00, those are the ones we wanna focus on first. If these are your top list, then we wanna pull the op notes or we wanna sit down with you and we wanna start giving you the documentation requirements so that you can start dictating in ICD-10 and we can start coding both in 9 and 10 to make sure that we can get a claim to go out the door quickly. Here we have our coding resources, our schedule for our upcoming AOS-sponsored courses that are presented by KCA. That list is available on our website. Information on our drop-down menu on workshops and at this point in time, let me go to some of the questions and I think I've answered a couple of these as I've looked at. We've talked about when exactly does an initial visit become a subsequent. I believe we've talked about that. There's a question about non-operative treatment of a fracture. Is it at the first follow-up office visit? Is it when sutures are removed? So the initial encounter, initial encounter for a non-operative treatment of a fracture will be the initial evaluation by you, the surgeon, or by your non-physician providers. They will see the patient. They will diagnose a non-displaced or minimally displaced fracture. They will decide, you will decide on the treatment. That is the initial encounter. When the patient returns for the next visit, it is a subsequent visit because you are no longer in the active treatment phase. That was done at the first encounter. Suture removal becomes a subsequent visit and we hope it's for routine healing. If the next question is, is the initial encounter for this particular physician correct? The initial encounter for this particular physician is correct. I'm not sure of that exact question, but the initial encounter is for each physician or provider who is evaluating the patient during the active treatment phase. More than one physician can report the initial encounter for the same patient for the same fracture. Next question, if a post-op patient is seen one week after surgery, for the fracture before sutures are removed, is this coded as an A or a D as the seventh code? It is going to be reported with the appropriate subsequent healing code. So in our ADF scenario, it is no longer A because it's post-op. So if the patient is seen before sutures are removed, the fracture has already been reduced or manipulated. If you are in the routine healing and everything is going well, you will use the D code or the appropriate other seventh character based on whether the castilla fracture classification or the torus or the green stick. So whatever the appropriate subsequent healing code is what you will report. Next question is patient with distal radius fracture is seen in the ER and the fracture is reduced and splinted. Patient returns to the office in one week and the fracture is well aligned. We code it with a D. Patient returns for a recheck in 10 days and the fracture is shifted and will need surgical correction. We go back to an A because we're now in the initial management of that fracture. And we're going to be an A until you reduce the fracture and then we're going to come back into subsequent healing for that fracture. I think we've talked about the initial and the sequela. A sequela is a late effect. It's a contracture after a finger fracture. It's a contracture after a patient's had a distal radius fracture and you've had them in a splint and they're not treating the patient. So initial encounter is the active phase of treatment. A sequela occurs after the patient has been treated for their initial fracture. They've gone through their routine healing and they now have what you used to call a late effect. We now call a sequela. Next question, I think that's the same question as we asked about the fracture. If there are no codes for both bone fractures and both are coded separately, which do you attach to your codes reduction CPT code of both bone fractures? If there are no codes for both bones and both, oh, CPT codes, for both bones and both, if I don't have, because there's not a combined code for both bone fractures, if you've got a radial shaft and an ulnar shaft, I code both the radial shaft and the ulnar shaft. So I will report both diagnosis codes for both fractures. If a patient has four metacarpal fractures, you will report all four appropriate metacarpal fractures for the appropriate extremity, for the appropriate metacarpal, first, second, third, fourth, as an example, base, shaft, or neck. You may have one of the metacarpals that is at the base, one's at the shaft, and one's at the neck. So I will actually have three different fracture codes. They're initially reported with the A for the initial encounter for each of those fracture codes. Next question is a new problem during a post-op period, how to code that. If it's just a new problem and it's unrelated, I'm gonna code it either from the S code, chapter 19 for an injury, or if it's a patient who comes in, they've had a wrist fracture, and you're in the global period for a wrist fracture, and they now come in with a trigger finger, then I code the trigger finger as using the appropriate M code for the appropriate extremity, for the appropriate digits. Trigger fingers, we now have a code for the right index, the left index, and the unspecified. Right middle, left middle, unspecified middle. Right ring, left ring, unspecified. My goal is that for you, the surgeons, that you can tell us specifically, it's the right, the left, it's the index, it's the middle, or the long, so that we can code this to the highest level of specificity. All right, I think that's all the questions. That's all I have for this evening. I thank you very much for participating. I hope you have an idea of how to build the codes, how to select the codes, and understanding of what the initial encounter is, what the subsequent encounter is, the application of going back and looking at the ICD-10 book specifically to know whether or not you're using a group of codes that has a three-category extension, six-category extension, seven-category extension, or the alphabet soup for all 16 codes. Again, those extensions that we talked about specifically in Chapter 19 relate to traumatic fractures and injuries found in Chapter 19. Olivia and Brenda, I'd like to thank you for the opportunity to speak this evening. Everyone have a good evening. Thank you, Mary, for that very informative presentation. That concludes the webinar for this evening. Please remain connected for a moment longer to give your feedback on this session, including your interest in additional ICD-10 webinars. A recording of tonight's webinar will be available by Friday. An email will be sent to you with instructions for online viewing. We will now launch the webinar survey. Thank you for participating, and we look forward to seeing you soon. Thank you.

webinar

fracture coding

ICD-10 system

documentation

anatomic location

type of fracture

laterality

Castillo classification

Salter-Harris classification

non-operative treatment

coding resources