Coding Tip: Periprosthetic Fracture Reporting and Sequencing
Kim Carrier RHIT, CDIP, CCS, CCS-P
Director of Coding Quality Assurance
AHIMA Approved ICD-10-CM/PCS Trainer
There are approximately 6.3 million fractures reported each year in the united states and most are due to trauma. Disease can also cause a bone to fracture and this fracture type is known as a pathological fracture. A pathological fracture is usually spontaneous but may also result from a minor trauma that fractures from the diseased bone. Osteoporosis alone is responsible for over a million fractures every year. Stress fractures are not as common but they do occur. There are more than 1 million total joint replacements in the U.S. each year, so there was a need to create codes for injuries that occur around or near the prosthesis. These are called “periprosthetic” fractures.
What is a Periprosthetic Fracture?
Periprosthetic fractures are fractures that occur around a prosthesis. They are not complications of the prosthesis but are caused by either trauma or disease (pathological). These fractures are not coded as a complication since they don’t actually involve the implant. ICD-10-CM has specific codes for periprosthetic fractures.
How is a Periprosthetic Fracture Coded and Sequenced?
Periprosthetic fractures are coded within Chapter 13 of ICD-10-CM in category M97. A minimum of two codes are required when reporting the periprosthetic fractures. One code for the periprosthetic fracture and another for the type of fracture, such as traumatic vs. pathological with the underlying condition. If the reason for admission/encounter is for the fracture then the fracture would be sequenced first and then the periprosthetic fracture code as a secondary diagnosis code.
Examples:
- Patient is admitted for new periprosthetic fracture of the lower end of the left femur after falling down 4 steps. This fracture is documented to not involve the actual joint prosthesis. In this case, report ICD-10-CM codes S72.402A (Unspecified fracture of lower end of left femur, initial encounter for closed fracture) as the principal/first listed diagnosis followed by M97.02XA (Periprosthetic fracture around internal prosthetic left hip joint, initial encounter) as a secondary diagnosis. (Also assign external cause codes)
- Patient is status post left shoulder replacement and presents for periprosthetic fracture of the humerus after rolling over in the bed. The patient was worked up and it was found that the fracture was due to underlying osteoporosis. There was no fracture of the actual joint prosthesis. In this case, report ICD-10 CM codes M84.422A (Pathological fracture, left humerus, initial encounter for fracture) as the principal/first listed diagnosis followed by M97.32XA (Periprosthetic fracture around internal prosthetic left shoulder joint, initial encounter) as a secondary diagnosis. (Also assign osteoporosis and external cause codes)
If the actual joint prosthesis is broken then the fracture would be coded as a complication of internal joint prosthesis and sequenced as the principal/first listed diagnosis code.
References
ncbi.nlm.nih.gov/pmc/articles/PMC5726208
https://www.niams.nih.gov/health-topics/hip-replacement-surgery
emedicine.medscape.com/article/1269334
orthoinfo.aaos.org/en/disease-conditions/fracture-after-total-hip-replacement/
I-10 Coding Handbook
ICD-10-CM/PCS Coding Clinic, Fourth Quarter ICD-10 2016 Page: 42
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2018 Page: 21
Happy Coding!
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
Popular Posts
Part 1: New 2021 CPT Codes | Integumentary System
This is Part 1 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include examples to help the coder understand the new codes. For 2021 in general, there were 199 new CPT codes added, 54 deleted and 69 revised.
2020: Year in Review | Coding Education
In January, new CPT codes were released. There were 248 new CPT codes added, 71 deleted and 75 revised. Most of the surgery section changes were in the musculoskeletal and cardiovascular subsections. These included procedures such as skin grafting, breast biopsies, deep drug delivery systems, tricuspid valve repairs, aortic grafts and repair of iliac artery.
Coding Tip: New COVID-19 Codes Effective January 1, 2021
We have seen many updates and changes to COVID-19 (SARS-CoV-2) since the pandemic started. On January 1, 2021 we will see even more changes as outlined in this post. Also the CMS MS-DRG grouper will be updated to version 38.1 to accommodate the changes.
New Technology Add-On Payments (NTAP) For FY2021 – Part 4
In the previous three parts of this four-part series, we discussed the new ICD-10-CM diagnosis code changes, ICD-10-PCS procedure code changes and FY2021 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2021.
New ICD Codes and IPPS Changes for FY2021 (ICD-10-CM Diagnoses changes) – Part 3
In the previous two parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes and ICD-10-PC procedure code changes. In this session we will review the major IPPS changes for FY2021.
Subscribe to our weekly newsletter
Latest News
Part 1: New 2021 CPT Codes | Integumentary System
This is Part 1 of a five part series on the new 2021 CPT codes. In this series we will explore the CPT changes for FY2021 and include examples to help the coder understand the new codes. For 2021 in general, there were 199 new CPT codes added, 54 deleted and 69 revised.
2020: Year in Review | Coding Education
In January, new CPT codes were released. There were 248 new CPT codes added, 71 deleted and 75 revised. Most of the surgery section changes were in the musculoskeletal and cardiovascular subsections. These included procedures such as skin grafting, breast biopsies, deep drug delivery systems, tricuspid valve repairs, aortic grafts and repair of iliac artery.
Coding Tip: New COVID-19 Codes Effective January 1, 2021
We have seen many updates and changes to COVID-19 (SARS-CoV-2) since the pandemic started. On January 1, 2021 we will see even more changes as outlined in this post. Also the CMS MS-DRG grouper will be updated to version 38.1 to accommodate the changes.
New Technology Add-On Payments (NTAP) For FY2021 – Part 4
In the previous three parts of this four-part series, we discussed the new ICD-10-CM diagnosis code changes, ICD-10-PCS procedure code changes and FY2021 IPPS changes. In this last Part 4 of the series, we will review the NTAP procedure codes and reimbursement add-on payments for FY2021.
New ICD Codes and IPPS Changes for FY2021 (ICD-10-CM Diagnoses changes) – Part 3
In the previous two parts of this four part series, we discussed the new ICD-10-CM diagnosis code changes and ICD-10-PC procedure code changes. In this session we will review the major IPPS changes for FY2021.
New ICD Codes and IPPS Changes for FY2021 (ICD-10-CM Diagnoses changes) – Part 2
This is Part 2 of a 4 part series on the FY2021 ICD-10 Code and IPPS changes. In this part, the ICD-10-PCS procedure codes are presented. For FY2021 ICD-10-PCS there are 78,115 total codes (FY2020 total was 77,571); 556 new codes (734 new last year in FY2020)…
New ICD Codes and IPPS Changes for FY2021 (ICD-10-CM Diagnoses changes) – Part 1
This is Part 1 of a 4 part series on the FY2021 changes to ICD-10 and the IPPS. In this part, we discuss some of the new ICD-10-CM diagnosis changes. Here is the breakdown: 72,616 total ICD-10-CM codes for FY2021; 490 new codes (2020 had 273 new codes); 58 deleted codes (2020 had 21 deleted codes); 47 revised codes (2020 had 30 revised codes)
Coding Tip: Reporting “Flash” Pulmonary Edema
Acute pulmonary edema is the rapid accumulation of fluid within the tissue and space around the air sacs of the lung (lung interstitium). When this fluid collects in the air sacs in the lungs it is difficult to breathe. Acute pulmonary edema occurs suddenly and is life threatening.
Client S: $556 increase/record reviewed
“Client S” is a small, not-for-profit, 40 bed micro-hospital in the Southeast. HIA performed a 65-record review this year for Client S and found an opportunity with 15 of them. 9 had an increased reimbursement with a total of $43,228 found.
Coding Tip: Glasgow Coma Scale Coding OCG Update for FY2021
The coma scale codes (R40.2-) can be used in conjunction with traumatic brain injury codes, acute cerebrovascular disease or sequelae of cerebrovascular disease codes. These codes are primarily for use by trauma registries, but they may be used in any setting where this information is collected. The coma scale may also be used to assess the status of the central nervous system for other non-trauma conditions, such as monitoring patients in the intensive care unit regardless of medical condition.
Coding Tip: Cardiac Arrest and Cardiac Shock
In the past, there had been an Excludes1 note at I46.- Cardiac arrest that excluded R57.0, Cardiac shock. HIA had also received a letter from AHA on a case in the past that had stated that only I46.- Cardiac arrest would be coded if both were documented. In addition, the Third Quarter Coding Clinic page 26 had a similar case that asked if both could be coded, and AHA had instructed that only I46.9, cardiac arrest, cause unspecified would be coded if both were documented and that the CDC would be looking at possible revision to the Excludes1 note.
Client X: Let’s Talk Numbers
A higher CMI corresponds to increased consumption of resources and increased cost of patient care, resulting in increased reimbursement to the facility from government and private payers, like CMS. We know that documentation directly impacts coding.
Coding Tip: Endarterectomy During Coronary Artery Bypass
Lately we have seen several cases where the endarterectomy was assigned along with the coronary artery bypass (CABG) procedure when being performed on the same vessel to facilitate the CABG. A coronary artery endarterectomy is not always performed during a CABG procedure, so when it is performed it becomes confusing as to whether to code it separately or not.
Coding Tip: Update – Coding COVID-19 When the Test is Negative
Assign code Z20.828, “Contact with and (suspected) exposure to other viral communicable diseases” for all patients who are tested for COVID-19 and the results are negative, regardless of symptoms, no symptoms, exposure or not as we are in a pandemic.
New ICD-10-PCS Procedure Codes for COVID-19
The Centers for Medicare & Medicaid Services (CMS) announced new procedure codes for treatments of COVID-19 – effective as of August 1, 2020. Among the new codes are Section X New Technology codes for the introduction or infusion of therapeutics including Remdesivir, Sarilumab, Tocilizumab, transfusion of convalescent plasma, as well as introduction of any other or new therapeutic substances for the treatment of COVID-19.
New Rule Helps Medicare ACOs During COVID-19 Pandemic
One common element in many value-based programs is risk adjustment using Hierarchical Condition Categories (HCCs) to create a Risk Adjustment Factor (RAF) score. This method ranks diagnoses into categories that represent conditions with similar cost patterns.
Part 5: Reasons for AKI Denials and Prevention | AKI Series
Why are so many AKI records being denied? It’s hard to give one answer for why so many AKI records are being denied lately, but most appear to be due to the multiple sets of criteria available for use in determining if a patient has AKI, as well as physician documentation. As stated in Part 3 of this series, there are three main criteria/classifications used to diagnose AKI.
Part 4: Is Documentation Present to Report Acute Kidney Injury/Failure? | AKI Series
In previous parts of this series we looked at the definitions of AKI/ARF, causes, coding and sequencing, and the common clinical indicators that patients present with that are diagnosed with this condition. In Part 4, we will look at the documentation that should be present to report the diagnosis without fear of denial, as well as when a query is needed to clarify the diagnosis.
Coding Tip: Z Code Reporting for COVID-19
If the facility does a COVID-19 test, and test is negative, do I need a diagnosis code. The answer is yes, you will report a Z-code. The Z-code depends on the record documentation and circumstances of testing. For any patient receiving a COVID-19 test, if negative, there MUST e a Z-code to describe why the test was taken. (Test negative for COVID-19 and MD does not override negative results).
Part 3: Clinical Indicators for Acute Kidney Injury/Failure | AKI Series
In the first parts of this series we looked at definitions of AKI/ARF, causes, coding and sequencing. In Part 3, we will look at what clinical indicators would possibly be present to support the diagnosis of AKI/ARF.
FY2021 Proposed Rule and Code Changes Highlights
The FY2021 IPPS Proposed Rule is out and here are some highlights from it regarding ICD-10 Code proposals. We will know if these changes are permanent after the public comment period is over on July 10, 2020 and CMS prepares the Final Rule, usually out by August 1.
Part 2: Specificity Coding of Acute Kidney Injury (AKI) and Sequencing | AKI Series
As discussed in Part 1 of this series, AKI/ARF is a common diagnosis that coders see daily. In Part 2, we are going to focus on the different types/specificity of AKI/ARF. We’ll learn what they mean, as well as how to code the diagnosis.
Part 1: What is Acute Kidney Injury (AKI)? | AKI Series
This is part 1 in a series focused on coding of acute kidney injury (AKI) and/or acute renal failure (ARF). AKI/ARF is reported often, but is also one of the most common diagnosis found in denials.
Reporting Telehealth Services During the COVID-19 Emergency
Effective March 1, Medicare will pay physicians for telehealth services at the same rate as in-person visits for all diagnoses, not just services related to COVID-19. This great for providers whose patients are reluctant to visit the office.
Coding Tip: What is Single Path Coding?
The biggest reasons why some hospital systems are moving to single path coding is to eliminate duplicative processes and to optimize productivity. In addition, costs are reduced when only one coder “touches” the record and completes both types of coding.
Coding Tip: Reporting Vaping in ICD-10-CM | Effective on 4/1/2020
Effective with 4/1/2020 discharges, ICD-10-CM code U07.0 is used to report vaping -related disorders. ICD-10-CM code U07.0 (vaping related disorder) should be used when documentation supports that the patient has a lung-related disorder from vaping. This code is found in the new ICD-10-CM Chapter 22. U07.0 will be in listed in the ICD-10-CM manual under a new section: Provisional assignment of new disease of uncertain etiology or emergency use.
Telehealth and the Coronavirus
The US government and public-health officials are urging consumers to utilize telemedicine for remote treatment, fill prescriptions and get medical attention during the new coronavirus pandemic. The goal is to keep people with symptoms at home and to practice social distancing if their condition doesn’t warrant more intensive hospital care.
Coronavirus: Tips for Working from Home
Coronavirus: Tips for working from home. Companies around the world have told their employees to stay home and work remotely. Whether you’re a new to this concept or a work from home veteran, here’s some tips to staying productive from our #HIAfamily.
Part 3: Coder and CDI Communication Example | CDI Series
This is the final part of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. In this part, we provide an actual example of an effective communication response to CDI.