Chapter 19

INJURY, POISONING, AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES

Introduction

Codes for injury, poisoning and certain other consequences of external causes are found in Chapter 19. Coding to the highest level of specificity for injuries requires extensive documentation. Documentation for injuries now requires more detailed information related to the type of injury, the specific location, and laterality to name a few. The requirements necessary for documentation of fractures discussed in Chapter 15 Musculoskeletal System is true for the majority of injuries in Chapter 19. In addition to the codes for injuries, Chapter 19 also includes a separate section for codes for burns, corrosions and frostbite. These, like the injury codes are classified first by location then by type and severity. The codes for adverse effects, poisoning, underdosing, and toxicity are combination codes that capture both the drug and the external cause. Finally, codes for consequences of external cause which includes complications due to past surgery or trauma are included in this chapter.

The majority of the codes related to injury, poisoning and certain complications also require the use of a 7th character to identify the episode of care. While episode of care is required only for some code categories in other chapters, the vast majority of codes in Chapter 19 require identification of the episode of care. One thing to note about episode of care codes is that there is no 7th character for “episode of care not otherwise specified.” Documentation must clearly identify the visit as the initial encounter, subsequent encounter, or sequela. The term ‘initial encounter’ is somewhat misleading as it actually refers to the period of time when the patient is receiving active treatment for the condition. Examples of encounters that would be for active treatment include: emergency department encounter, surgical treatment, and evaluation and continuing treatment by the same or a different physician. Active treatment is based upon whether the patient is undergoing active treatment not whether the provider is seeing the patient for the first time. Active treatment should not be confused with ongoing management of the condition during the healing phase.

Injuries and poisoning should also have documentation of the external cause of injury. This is particularly important in the inpatient acute care setting for trauma registry purposes. External cause coding and documentation requirements will be reviewed in Chapter 20. However, because the external cause is integral to complete coding and documentation for injury and poisoning, a brief review of the types of information captured by these codes is included here. External cause codes identify the following:

•Cause of injury (such as fall, auto accident, gunshot wound)

•Place of occurrence (such as home, school, work, highway, park, wilderness area)

•Activity (such as shoveling snow, swimming, showering/bathing)

•External cause status (civilian activity done for pay/income, military activity, volunteer activity, hobby, leisure, student)

The documentation and coding examples in this chapter include external cause, place of occurrence, activity and external cause status. These have also been coded in the examples but will be covered more thoroughly in Chapter 20.

Organization of Injury Codes

Injury codes are organized first by body area and then by type of injury. The code blocks are listed below. When reviewing the injury code blocks it is helpful to remember that the second character identifies the body area. For example, all injuries related to the foot and ankle will have a second character of 9 (S90-S99).

ICD-10-CM Blocks
S00-S09	Injuries to the Head
S10-S19	Injuries to the Neck
S20-S29	Injuries to the Thorax
S30-S39	Injuries to the Abdomen, Lower Back, Lumbar Spine, Pelvis, and External Genitals
S40-S49	Injuries to the Shoulder and Upper Arm
S50-S59	Injuries to the Elbow and Forearm
S60-S69	Injuries to the Wrist, Hand and Fingers
S70-S79	Injuries to the Hip and Thigh
S80-S89	Injuries to the Knee and Lower Leg
S90-S99	Injuries to the Ankle and Foot
T07	Injuries Involving Multiple Body Regions
T14	Injury of Unspecified Body Region
T15-T19	Effects of Foreign Body Entering Through Natural Orifice
T20-T25	Burns and Corrosions of External Body Surface, Specified by Site
T26-T28	Burns and Corrosions Confined to Eye and Internal Organs
T30-T32	Burns and Corrosions of Multiple and Unspecified Body Regions
T33-T34	Frostbite
T36-T50	Poisoning by, Adverse Effects of and Underdosing of Drugs, Medicaments and Biological Substances
T51-T65	Toxic Effects of Substances Chiefly Nonmedicinal as to Source
T66-T78	Other and Unspecified Effects of External Causes
T79	Certain Early Complications of Trauma
T80-T88	Complications of Surgical and Medical Care, Not Elsewhere Classified

Coding Notes

In ICD-10-CM, there are some important coding notes and instructions at the beginning of the chapter. The first note references the need to use secondary codes from Chapter 20 External Causes of Morbidity, to indicate cause of injury. Some codes in Chapter 19, such as codes for toxic effects of drugs and chemicals, include the external cause and do not require an additional external cause code for the intent. The second note is a ‘use additional code’ instruction to identify any retained foreign body, if applicable (Z18.-).

There are no instructions at the beginning of Chapter 19 related to coding of multiple injuries. Instead, coding instructions related to multiple injuries are now provided in the guidelines. There are also no instructions for coding late effects of injuries. In ICD-10-CM late effects are considered sequelae. Instructions related to coding of sequelae are also found in the guidelines. One thing to note is that codes for sequelae of injuries are reported with the same code as the injury with a 7th character ‘S’ to identify that the encounter/treatment is for a sequela of the injury.

Exclusions

Chapter 19 in ICD-10-CM lists trauma diagnoses that are excluded from the injury and poisoning chapter.

Excludes 1	Excludes2
Birth trauma (P10-P15) Obstetric trauma (O10-O71)	None

Chapter Guidelines

There are detailed guidelines for the majority of the sections in Chapter 19. The guideline topics are listed below with detailed information on each of these guidelines to follow.

•Application of 7th characters

•Coding of injuries

•Coding of traumatic fractures

•Coding of burns and corrosions

•Adverse effects, poisoning, underdosing, and toxic effects

•Adult and child abuse, neglect, and other maltreatment

•Complications of care

Application of 7th Characters

Most categories in the injury and poisoning chapter require assignment of a 7th character to codes to identify the episode of care. For most categories, there are three 7th character values to select from: ‘A’ for initial encounter; ‘D’ for subsequent encounter; and ’S’ for sequela. Categories for fractures are an exception with fractures having six to sixteen 7th character values. The 7^th character value for fractures is necessary to capture additional information about the fracture, including whether it is open or closed and whether the healing phase is routine or complicated by delayed healing, nonunion, or malunion. Detailed guidelines are provided related to selection of the 7th character value. Related guidelines and some examples of encounters representative of the three episode of care 7th character values found in the majority of categories are as follows:

AInitial encounter. Initial encounter is defined as the period when the patient is receiving active treatment for the injury, poisoning, or other consequences of an external cause. An ‘A’ may be assigned on more than one claim. For example, if a patient is seen in the emergency department (ED) for a head injury that is first evaluated by the ED physician who requests a CT scan, which is read by a radiologist and a consultation by a neurologist, the 7th character ‘A’ is used by all three physicians and also reported on the ED claim. If the patient required admission to an acute care hospital, the 7th character ‘A’ would be reported for the entire acute care hospital stay because the 7th character extension ‘A’ is used for the entire period that the patient receives active treatment for the injury.

DSubsequent encounter. This is an encounter after the active phase of treatment and when the patient is receiving routine care for the injury or poisoning during the period of healing or recovery. Unlike aftercare following medical or surgical services for other conditions which are reported with codes from Chapter 21 Factors Influencing Health Status and Contact with Health Services (Z00-Z99), aftercare for injuries and poisonings is captured by the 7th character ‘D’. For example, a patient with an ankle sprain may return to the office to have joint stability re-evaluated to ensure that the injury is healing properly. In this case, the 7th character ‘D’ would be assigned.

SSequela. The 7th character extension ‘S’ is assigned for complications or conditions that arise as a direct result of an injury. An example of a sequela is a scar resulting from a burn.

Coding of Injuries

General coding and sequencing guidelines for injuries are as follows:

•Separate codes are required for each injury unless a combination code is provided, in which case the combination code should be used

•The code for unspecified multiple injuries (T07) should not be assigned in the inpatient setting unless more specific information about the injuries is not available. This would be an extremely rare occurrence

•Traumatic injury codes (S00-T14.9) are not used to report normal, healing surgical wounds or complications of surgical wounds

•Sequencing of injury codes

–The most serious injury as determined by the provider and the focus of treatment based on the provider’s documentation is sequenced first

–Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site. For example, a closed fracture sustained in a fall with contusions at the fracture site would require coding of the fracture only. The contusions are considered superficial injuries and would not be coded.

–Determining the primary injury for injuries that occur with damage to nerves and blood vessels

»When a primary injury occurs with minor damage to nerves and/or blood vessels, the primary injury is sequenced first followed by additional codes for injuries to nerves and spinal cord and/or codes for injuries to blood vessels

»When the primary injury is to a blood vessel or nerves, the blood vessel or nerve injury is sequenced first

Coding of Traumatic Fractures

The overall principles for coding traumatic fractures are the same as for other injuries but more expansive. Guidelines are as follows:

•A fracture not indicated as open or closed is coded as closed

•A fracture not indicated as displaced or nondisplaced is coded as displaced

•Multiple fractures:

–When there are multiple fractures, a separate code is required for each specified fracture site in accordance with instructions provided at the category and subcategory level and the level of detail documented in the medical record.

–Multiple fractures are sequenced in accordance with the severity of the fracture as documented by the provider. The provider should be asked to list fracture diagnoses in order of severity

•Initial versus subsequent encounter for fractures and assignment of 7th character extensions:

–Initial encounter – 7th character extensions A, B, C

»Use an initial encounter 7th character extension when the patient is receiving active treatment for the fracture, which includes emergency department encounter, surgical treatment, and evaluation and continuing (ongoing) treatment by the same or a different physician. Active treatment is based upon whether the patient is undergoing active treatment not whether the provider is seeing the patient for the first time.

»Use initial encounter 7th character extensions for individuals who delayed seeking treatment for the fracture or delayed seeking treatment for a nonunion

–Subsequent encounter – 7th character extensions D, E, F, G, H, J, K, M, N, P, Q, R

»Use a subsequent encounter 7th character extension when the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase

»Routine aftercare for the fracture includes: cast change or removal, an x-ray to check healing status of a fracture, removal of external or internal fixation device, medication adjustment, other follow-up visits for fracture aftercare

»Aftercare Z codes are not used for aftercare of traumatic fractures

•Complications of fractures:

–Any complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication code

–Delayed healing, nonunion, and malunion are reported with the appropriate 7th character extensions for subsequent care as follows:

»Delayed healing – G, H, J

»Nonunion – K, M, N

»Malunion – P, Q, R

»Assign the appropriate 7^th character for initial visit not subsequent encounter for a patient with a nonunion/malunion who delayed seeking treatment and is being evaluated for the first time.

•Fractures in a patient with known osteoporosis:

–Do not use a traumatic fracture code for a patient with known osteoporosis who suffers a fracture even when the fracture occurs after a minor fall or trauma if that fall or trauma would not normally break a normal, healthy bone

–A code from category M80 Osteoporosis with current pathological fracture, should be reported in the above described instance

•Other nontraumatic fractures are reported with codes from Chapter 13 Diseases of the Musculoskeletal System and Connective Tissue:

–Fatigue fracture of vertebrae (M48.4)

–Stress fracture (M84.3)

–Pathological fracture, not elsewhere classified (M84.4)

–Pathological fracture in neoplastic disease (M84.5)

–Pathological fracture in other disease (M84.6)

–Atypical femoral fracture (M84.7)

Coding of Burns and Corrosions

Burns are classified first by type, thermal or corrosion burns, and then by depth and extent. Corrosions are burns due to chemicals. Thermal burns are burns that come from a heat source but exclude sunburns. Examples of heat sources include fire, hot appliance, electricity, and radiation.

The guidelines are the same for both corrosions and thermal burns with one exception—corrosions require identification of the chemical substance. The chemical substance that caused the corrosion is the first listed diagnosis. The chemical substance is found in the Table of Drugs and Chemicals. Codes for drugs and chemicals are combination codes that identify the substance and the external cause or intent, so an external cause of injury code is not required. However, codes should be assigned for the place of occurrence, activity, and external cause status. Guidelines for the use of the external cause codes can be found in Chapter 20 External Causes of Morbidity. The correct code for an accidental corrosion is found in the column for poisoning, accidental (unintentional).

Classification of Current Burns

Current corrosions and thermal burns are classified by:

•Depth

–First degree (erythema)

–Second degree (blistering)

–Third degree (full thickness involvement)

•Extent

–Total body surface burned

–Total body surface with third degree burns

•Agent

–Corrosive (T-code)

»Acids

»Alkalines

»Caustics

»Chemicals

–Thermal (except sunburn) (X-code)

»Electricity

»Flame

»Heat (gas, liquid, or object)

»Radiation

»Steam

The agent can be found in the Table of Drugs and Chemicals for corrosions and in the Alphabetic Index to External Causes for thermal burns.

Note: Burns of the eye and internal organs are classified by site but not by degree.

Sequencing of Burn Codes

Coding Guidelines for burns, related conditions, and complications of burns are as follows:

•Sequencing of multiple burns and/or burn injuries with related conditions:

–Multiple external burns only. When more than one external burn is present, the first listed diagnosis code is the code that reflects the highest degree burn

–Internal and external burns. The circumstances of the admission or encounter govern the selection of the principle or first-listed diagnosis

–Burn injuries and other related conditions such as smoke inhalation or respiratory failure. The circumstances of the admission or encounter govern the selection of the principal or first-listed diagnosis

•Assign separate codes for each burn site

•Burns of the same anatomic site

–Classify burns of the same anatomic site and on the same side but of different degrees to the subcategory identifying the highest degree recorded in the diagnosis (e.g., for second and third degree burns of right thigh, assign only code T24.311-)

•Burns of unspecified site

–Codes from category T30 Burn and corrosion, body region unspecified, is extremely vague and should rarely be used

•Classifying burns and corrosions by extent of body surface area involved:

–A code from category T31 Burns classified according to extent of body surface involved, or T32 Corrosions classified according to extent of body surface involved, may be reported as the first listed diagnosis when:

»The site of the burn is not specified

»There is a need for additional information on the extent of the burns

–Codes from category T31 should be used whenever possible to:

»Provide data for evaluating burn mortality, such as that needed by burn units

»When there is mention of a third-degree burn involving 20% or more of body surface

–Rule of nines - Extent of body surface for categories T31 and T32 are governed by the rule of nines as follows:

»Head and neck – 9%

»Each arm – 9%

»Each leg – 18%

»Anterior trunk – 18%

»Posterior trunk – 18%

»Genitalia – 1%

Note: Providers may modify these percentages for infants and children who have larger heads than adults and for adults with large buttocks, thighs, and abdomens when those regions are burned.

•Non-healing and infected burns:

–Non-healing burns are coded as acute burns with 7th character extension ‘A’

–Necrosis of burned skin is coded as a non-healing burn

–Infected burns require use of an additional code for the infection

•Late effects/sequelae of burns:

–Sequelae are reported using a burn or corrosion code with the 7th character ‘S’

–Both a code for a current burn or corrosion code and a code for sequela may be assigned on the same record. It is possible for a patient to receive treatment for a current burn and treatment for sequela because corrosions and burns do not heal at the same rate.

•External cause codes are reported additionally for burns and corrosions to:

–Identify the source and intent of the burn (X-code) or corrosion (T-code)

–Place of occurrence

–Activity

–External cause status

Adverse Effects, Poisoning, Underdosing, and Toxic Effects

Codes for adverse effects, poisoning, underdosing, and toxic effects are combination codes that include both the substance taken and the intent. No additional external cause code is reported with these codes.

Locating the correct code for the drug, medicament, other biological substance, or nonmedicinal substance is done as follows:

•Use the Table of Drugs and Chemicals to find the correct drug or other substance

•Identify the condition:

–Poisoning (includes toxic effect)

»Accidental

»Intentional self-harm

»Assault

»Undetermined

–Adverse effect

–Underdosing

Note: For toxic effect of substances chiefly nonmedicinal as to source (T51-T65), when no intent is indicated, code to accidental. Undetermined intent is only for use when there is specific documentation to indicate that the intent of the toxic effect cannot be determined

•Refer to the Tabular list to verify code selection

•Use as many codes as necessary to describe completely all drugs, medicinal, biological, or other substances responsible for the adverse effect, poisoning, underdosing, or toxic effect

•If a single causative agent has resulted in more than one adverse effect, poisoning, underdosing, or toxic effect list the code for the causative agent only once

•If two or more drugs or other substances are responsible for the adverse effect, poisoning, underdosing, or toxic effect, assign a code for each one individually unless a combination code is available

Toxicity due to drugs or other substances is classified in ICD-10-CM as:

•Adverse effect

•Poisoning

•Underdosing

•Toxic Effect

Guidelines and sequencing of adverse effect, poisoning, underdosing, and toxic effects are as follows:

•Adverse effect

–Defined as a drug or other substance that has been correctly prescribed and properly administered

–Sequencing of codes for adverse effect:

»In I.C.19.e.5(a) it states, “assign the appropriate code for the nature of the adverse effect followed by the appropriate code for the adverse effect of the drug (T36-T50)”

»There is also an instruction in the Tabular List for the code block T36-T50 that states, “Code first, for adverse effects, the nature of the adverse effect”

•Poisoning

–Defined as the improper use of a drug or other substance which includes:

»Overdose

»Wrong substance given or taken

»Wrong route of administration

»Nonprescribed drug taken with correctly prescribed and properly administered drug

»Interaction of drugs and alcohol

–Sequencing of codes for poisoning:

»The appropriate poisoning code(s) which includes the intent (T36-T50) is sequenced first

»The code(s) that specify the manifestation(s) of the poisoning are listed as additional code(s)

•Underdosing

–Defined as taking less of a medication than is prescribed by the provider or the manufacturer’s instructions. Discontinuing the use of a prescribed medication on the patient’s own initiative, not directed by the patient’s provider, is also classified as underdosing

–Sequencing of codes for underdosing:

»Underdosing codes are never assigned as the principal or first-listed code

»Assign the code for the relapse or exacerbation of the medical condition for which the drug is prescribed as the principal or first-listed code

»Assign the code for the underdosing as an additional code

»Assign an additional code for noncompliance, if known (Z91.12-, Z91.13-, and Z91.14-) to capture intent

»Assign an additional code for complication of care, if known (Y63.8-, Y63.9) to capture intent

•Toxic effects

–Defined as ingesting or coming in contact with a harmful substance that is chiefly non-medicinal as to source

–Use for toxic effect of substances chiefly nonmedicinal as to source (T51-T65)

–Toxic effects are captured with poisoning codes and have an associated intent (accidental, intentional self-harm, assault, undetermined)

»When no intent is indicated, code to accidental

»Undetermined intent is only for use when there is specific documentation to indicate that the intent of the toxic effect cannot be determined

–The appropriate toxic effect code, which includes the intent (T51-T65), is sequenced first

–The code(s) that specify the manifestation(s) of the toxic effect are listed as additional code(s).

Adult and Child Abuse, Neglect, and Other Maltreatment

If the documentation in the health record indicates that there is known or suspected neglect or abuse of a child or adult, a code from category T74 Adult and child abuse, neglect and other maltreatment, confirmed; or T76 Adult and child abuse, neglect and other maltreatment, suspected is assigned as the first-listed diagnosis. Additional code(s) are reported to capture mental health conditions or injuries resulting from the confirmed or suspected abuse or neglect. The Guidelines are below.

•Confirmed abuse or neglect codes are reported with external cause and perpetrator codes which are sequenced as follows:

–A code from category T74 Adult and child abuse, neglect and other maltreatment, confirmed, is sequenced first

–Codes for mental health conditions or injuries resulting from the abuse or neglect are coded additionally

–An external cause code from the assault section (X92-Y08) is reported

–A perpetrator code from category Y07 is reported when the perpetrator is known

•Suspected abuse or neglect codes are reported as follows:

–A code from category T76 Adult and child abuse, neglect and other maltreatment, suspected, is sequenced first

–Codes for mental health conditions or injuries resulting from the abuse or neglect are coded additionally

–No external cause codes or perpetrator are reported when the abuse or neglect is documented as suspected

–If suspected abuse or neglect is ruled out during the encounter, do not report a code from category T76. Report one of the following codes instead:

»Z04.71 Encounter for examination and observation following alleged physical adult abuse, ruled out

»Z04.72 Encounter for examination and observation following alleged physical child abuse, ruled out

–If suspected rape or sexual abuse is ruled out during the encounter, do not report a code from category T76. Report one of the following codes instead:

»Z04.41 Encounter for examination and observation following alleged adult rape

»Z04.42 Encounter for examination and observation following alleged child rape

–If suspected forced sexual exploitation or forced labor exploitation is ruled out during the encounter, do not report a code from category T76. Report one of the following codes instead:

»Z04.81 Encounter for examination and observation of victim following forced sexual exploitation

»Z04.82 Encounter for examination and observation of victim following forced labor exploitation

Complications of Care

Complications of surgical and medical care, not elsewhere classified are reported with codes from categories T80-T88. However, intraoperative and post-procedural complications are reported with codes from the body system chapters. For example, ventilator associated pneumonia is considered a procedural or post-procedural complication and is reported with code J95.851 Ventilator associated pneumonia, from Chapter 10 Diseases of the Respiratory System.

Complication of care code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure. Not all conditions that occur following medical or surgical treatment are classified as complications. Only those conditions for which the provider has documented a cause-and-effect relationship between the care and the complication should be classified as complications of care. If the documentation is unclear, query the provider.

Some complications of care codes include the external cause in the code. These codes include the nature of the complication as well as the type of procedure that caused the complication. An additional external cause code indicating the type of procedure is not necessary for these codes.

Pain due to medical devices, implants, or grafts require two codes, one from the T-codes to identify the device causing the pain, such as T84.84-, Pain due to internal orthopedic prosthetic devices, implants and grafts, and one from category G89 to identify acute or chronic pain due to presence of the device, implant, or graft.

Transplant complications are reported with codes from category T86. These codes should be used for both complications and rejection of transplanted organs. A transplant complication code is assigned only when the complication affects the function of the transplanted organ. Two codes are required to describe a transplant complication, one from category T86 and a secondary code that identifies the specific complication.

Patients who have undergone a kidney transplant may still have some form of chronic kidney disease (CKD) because the transplant may not fully restore kidney function. CKD is not considered to be a transplant complication unless the provider documents a transplant complication such as transplant failure or rejection. If the documentation is unclear, the provider should be queried. Other complications (other than CKD) that affect function of the kidney are assigned a code from subcategory T86.1 Complications of transplanted kidney, and a secondary code that identifies the complication.

General Documentation Requirements

There are some specific documentation requirements for injuries, poisonings, and other consequences of external causes. In this section, we will discuss fracture classification systems, 7th character extensions for fractures, and laterality. It is important to note that because the 7^th character extension defines the episode of care as well as whether the fracture was open or closed the level of detail (fracture level, type, open vs closed) must be documented for every encounter. The codes cannot be determined based upon previous documentation.

Fracture Classification Systems

Some of the most important documentation requirements for injuries relate to fractures. Some fractures such as surgical neck fractures of the humerus, physeal fractures, and open fractures of the long bones are coded using specific classification systems. Three of these classification systems are discussed here and they include:

•Neer classification for fracture of the proximal or upper end of the humerus

•Gustilo classification for open fracture of the long bones

•Salter-Harris classification for physeal fractures

Neer Classification

Fractures of the proximal or upper end of the humerus are classified using the Neer system. The proximal humerus is divided into four parts, the humeral head, greater tubercle, lesser tubercle, and diaphysis or shaft. These four parts are separated by epiphyseal lines, also called growth plates, when the bones are still growing during the developmental years. The surgical neck is at the narrowest aspect of the humerus just below the tubercles. When the proximal humerus is fractured, it typically occurs at the surgical neck and along one or more of the three epiphyseal lines. The proximal humerus may fracture into 2, 3, or 4 parts at the surgical neck which is why surgical neck fractures are designated as 2-part, 3-part or 4-part fractures.

The classification of the fracture is based upon the number of fragments and whether there is separation or angulation of the fragments. A fracture part is considered displaced if it is angulated more than 45^o or displaced greater than 1 cm. A fracture that is not displaced <1cm and angulated < 45^o regardless of how many pieces is considered a one-part fracture. All other Neer classifications are based upon the total number of fractures and the number of fractures that are displaced or angulated. For example, a 2-part fracture can be 2-4 parts with one of those parts being displaced or angulated. A three-part fracture can be 3-4 parts with two of the parts being displaced or angulated

Gustilo Classification

The Gustilo classification applies to open fractures of the long bones including the humerus, radius, ulna, femur, tibia, and fibula. The Gustilo open fracture classification groups open fractures into three main categories designated as Type I, Type II, and Type III with Type III injuries being further divided into Type IIIA, Type IIIB, and Type IIIC subcategories. The categories are defined by three characteristics which include:

•Mechanism of injury

•Extent of soft tissue damage

•Degree of bone injury or involvement

In order to assign the correct code for open fractures of the long bones, the specific characteristics for each type must be understood. The specific characteristics are as follows:

Type I

•Wound < 1 cm

•Minimal soft tissue damage

•Wound bed is clean

•Typically, low-energy type injury

•Fracture type is typically one of the following:

–Simple transverse

–Short oblique

–Minimally comminuted

Type II

•Wound > 1 cm

•Moderate soft tissue damage/crush injury

•Moderate wound bed contamination

•Typically, low-energy type injury

•Fracture type is typically one of the following:

–Simple transverse

–Short oblique

–Mildly comminuted

Type III

•Wound > 1 cm

•Extensive soft tissue damage

•Typically, a high-energy type injury

•Highly unstable fractures often with multiple bone fragments

•Injury patterns resulting in fractures that are always classified to this category include:

–Open segmental fracture regardless of wound size

–Diaphyseal fractures with segmental bone loss

–Open fractures with any type of vascular involvement

–Farmyard injuries or severely contaminated open fractures

–High velocity gunshot wound

–Fracture caused by crushing force from fast moving vehicle

–Open fractures with delayed treatment (over 8 hours)

Type IIIA

•Wound <10cm with crushed tissue and contamination

•Adequate soft tissue coverage of open wound

•No local or distant flap coverage required

•Fracture may be open segmental or severely comminuted and still be subclassified as Type IIIA

Type IIIB

•Wound >10cm with crushed tissue, massive contamination and extensive soft tissue loss

•Local or distant flap coverage required

•Wound bed contamination requiring serial irrigation and debridement to clean the open fracture site

Type IIIC

•Major arterial injury requiring repair regardless of size of wound

•Extensive repair usually requiring the skills of a vascular surgeon is required for limb salvage

•Fractures classified using the Mangled Extremity Severity Score

•Often results in amputation

Providers should be encouraged to identify the Gustilo type in documentation related to fractures of the long bones, but in the absence of documentation of a specific type of fracture, the coder may be able to determine the correct code assignment using the descriptions above. However, the correct classification should also be verified by the physician.

Salter-Harris Classification

Physeal fractures may also be referred to as Salter-Harris fractures or traumatic epiphyseal separations. These fractures occur along the epiphyseal (growth) plates in bones that have not reached their full maturity and in which the plates are still open and filled with cartilaginous tissue. They are listed in the alphabetic index under the main term ‘fracture’ traumatic and then by site under the term ‘physeal’.

Salter-Harris fractures are classified into 9 types. Documentation as to type is required to assign the most specific code. Types I-IV have specific codes for most sites. Types V-IX are reported under other physeal fracture. If no type is specified, the Salter-Harris fracture is reported with an unspecified code.

Types I-IV are the most common types of physeal injuries and have the following characteristics:

•Type I – Epiphyseal separation with displacement of the epiphysis from the metaphysis at the physis

•Type II – Fracture through the physis and a portion of the metaphysis without fracture of the epiphysis

•Type III – Fracture through the physis and epiphysis which damages the reproductive layer of the physis

•Type IV – Fracture through the metaphysis, physis, and epiphysis causing damage to the reproductive layer of the physis

Types V-IX are less common types of physeal injuries, which are determined as follows:

•Type V – A crush or compression injuring involving the physis without fracture of the metaphysis or epiphysis

•Type VI – A rare injury involving perichondral structures

•Type VII – An isolated injury of the epiphyseal plate

•Type VIII – An isolated injury to the metaphysis with potential complications related to endochondral ossification

•Type IX – An injury to the periosteum that may interfere with membranous growth

7th Character Extensions for Fractures

7th character extensions are used capture the episode of care for most injuries, poisonings, and other consequences of external causes. Fractures require 7th character extensions, but these extensions differ from those used for other types of injuries. The 7th character fracture extensions capture the following:

•Episode of care

•The status of the fracture as open or closed

–The Gustilo classification for open fractures of the long bones

•Healing status of the fracture for subsequent encounters:

–Routine healing

–Delayed healing

–Malunion

–Nonunion

The applicable 7th character extensions for most fractures are as follows:

AInitial encounter for closed fracture

BInitial encounter for open fracture

DSubsequent encounter for fracture with routine healing

GSubsequent encounter for fracture with delayed healing

KSubsequent encounter for fracture with nonunion

PSubsequent encounter for fracture with malunion

SSequela

The applicable 7th character extensions for fractures of the shafts of the long bones are as follows:

AInitial encounter for closed fracture

BInitial encounter for open fracture type I or II or open fracture NOS

CInitial encounter for open fracture type IIIA, IIIB, or IIIC

DSubsequent encounter for closed fracture with routine healing

ESubsequent encounter for open fracture type I or II with routine healing

FSubsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing

GSubsequent encounter for closed fracture with delayed healing

HSubsequent encounter for open fracture type I or II with delayed healing

JSubsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing

KSubsequent encounter for closed fracture with nonunion

MSubsequent encounter for open fracture type I or II with nonunion

NSubsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion

PSubsequent encounter for closed fracture with malunion

QSubsequent encounter for open fracture type I or II with malunion

RSubsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

SSequela

Laterality

The vast majority of injuries to paired organs and the extremities require documentation of the organ or extremity as the right or left. In addition, some injuries such as open wounds of the thorax, require documentation of the site as the right back wall, left back wall, right front wall or left front wall. For open wounds of the abdominal wall, documentation must identify the site as right upper quadrant, left upper quadrant, epigastric region, right lower quadrant, or left lower quadrant.

Injury and Poisoning Documentation Requirements

In this section, some of the more frequently reported injury, poisoning, and other consequences of external causes code categories, subcategories, and subclassifications are reviewed and the documentation requirements are identified. The focus is on frequently reported conditions with specific clinical documentation requirements. Even though not all codes with significant documentation requirements are discussed, this section will provide a representative sample of the type of documentation required for injury, poisoning, and other consequences of external causes. The section is organized alphabetically by the code category, subcategory, or subclassification depending on whether the documentation affects only a single code or an entire subcategory or category. If injuries of multiple areas are reviewed such as fractures, the sections will then be further organized by anatomic order based upon the ICD-10-CM categories.

Burns

Burns are classified first as chemical or thermal burns and then by depth and extent. Chemical burns are classified as corrosions and thermal burns are classified as burns. A toxic effect code provides more information on the type of agent that caused the corrosion or burn and on the intent (accidental, intentional self-harm, assault, undetermined). Burns of the same local site but of different degrees are coded to the highest degree documented. Non-healing burns are coded as acute burns. Necrosis of burned skin is coded as non-healing burn.

Coding and Documentation Requirements

Identify type of burn:

•Corrosion, which includes burns due to

–Acids

–Alkalines

–Caustics

–Chemicals

•Thermal (except sunburn), which includes burns due to

–Electricity

–Flame

–Heat (gas, liquid, or object)

–Radiation

–Steam

Identify site:

•External – See ICD-10-CM book for sites

•Eye and adnexa only

–Eyelid and periocular area

–Cornea and conjunctival sac

–Resulting in rupture and destruction of eyeball

–Other specified parts of eye/adnexa

–Unspecified part of eye

•Internal – See ICD-10-CM book for sites

Identify laterality:

•Right

•Left

•Unspecified

Identify depth:

•First degree-erythema

•Second degree-blisters, epidermal loss

•Third degree-full thickness skin loss, deep necrosis of underlying tissue

•Unspecified degree

Identify extent of total body surface area (TBSA):

•Less than 10%

•10-19%

–With 0-9% third degree

–With 10-19% third degree

•20-29%

–With 0-9% third degree

–With 10-19% third degree

–With 20-29% third degree

•30-39%

–With 0-9% third degree

–With 10-19% third degree

–With 20-29% third degree

–With 30-39% third degree

•40-49%

–With 0-9% third degree

–With 10-19% third degree

–With 20-29% third degree

–With 30-39% third degree

–With 40-49% third degree

•50-59%

–With 0-9% third degree

–With 10-19% third degree

–With 20-29% third degree

–With 30-39% third degree

–With 40-49% third degree

–With 50-59% third degree

•60-69%

–With 0-9% third degree

–With 10-19% third degree

–With 20-29% third degree

–With 30-39% third degree

–With 40-49% third degree

–With 50-59% third degree

–With 60-69% third degree

•70-79%

–With 0-9% third degree

–With 10-19% third degree

–With 20-29% third degree

–With 30-39% third degree

–With 40-49% third degree

–With 50-59% third degree

–With 60-69% third degree

–With 70-79% third degree

•80-89%

–With 0-9% third degree

–With 10-19% third degree

–With 20-29% third degree

–With 30-39% third degree

–With 40-49% third degree

–With 50-59% third degree

–With 60-69% third degree

–With 70-79% third degree

–With 80-89% third degree

•More than 90%

–With 0-9% third degree

–With 10-19% third degree

–With 20-29% third degree

–With 30-39% third degree

–With 40-49% third degree

–With 50-59% third degree

–With 60-69% third degree

–With 70-79% third degree

–With 80-89% third degree

–With more than 90% third degree

Identify agent and intent:

•Agent (corrosion) – See code range T51-T65 in ICD-10-CM for agents

•Intent

–Accidental (unintentional)

–Intentional self-harm

–Assault

–Undetermined

Example 1

Corrosion, First Degree, Fingers Not Including Thumb

ICD-10-CM Code/Documentation
T23.521-	Corrosion of first degree of single right finger (nail) except thumb
T23.522-	Corrosion of first degree of single left finger (nail) except thumb
T23.529-	Corrosion of first degree of unspecified single finger (nail) except thumb
T23.531-	Corrosion of first degree of multiple right fingers (nail) not including thumb
T23.532-	Corrosion of first degree of multiple left fingers (nail) not including thumb
T23.539-	Corrosion of first degree of unspecified multiple fingers (nail) not including thumb

Note: Only the burn codes are listed in the table above. Additional codes are required to identify the chemical and intent (external cause). See scenario below for an example.

Documentation and Coding Example

Patient is a sixty-eight your old gentleman who presents to ED with intense pain in the tips of his right index and middle fingers. He states he attended a decorative glass workshop at the local Adult Education Center earlier in the day and was handling dilute hydrofluoric acid that spilled but he believed he had cleaned it up without contaminating himself. He looked up symptoms of chemical burns on the internet when the pain began and decided it would be best to have it checked out. On examination, this is a small, thin, immaculately groomed Asian male who looks younger than his stated age. He states he is a retired mathematics professor and enjoys studying art. No significant PMH, he takes OTC vitamins and nutritional supplements for recently diagnosed macular degeneration. Temperature 98.6, HR 66, RR 12, BP 120/70. The tips of the index and middle fingers on the right hand have small white patches measuring <0.25 cm with surrounding erythema. The pain is most pronounced in that area and he describes it as deep and throbbing. Calcium gluconate 2.5 % gel applied to area and blood is drawn for CBC and serum electrolytes including stat magnesium, calcium, and potassium. X-ray of right index and middle fingers also obtained to check bone integrity. Pain has decreased substantially with application of topical calcium gluconate. X-ray shows no bone damage. Serum electrolytes are WNL.

Impression: Grade I Hydrofluoric acid burn to tips of two fingers, no systemic involvement. Discharged with index and middle fingers immersed in 2.5 % Calcium gluconate gel covered with vinyl glove. He is instructed to limit use of hand and to keep glove in place x 24 hours. He is given a follow up appointment tomorrow in burn clinic.

Diagnosis Code(s)

T54.2X1A	Toxic effect of corrosive acids and acid-like substances, accidental (unintentional), initial encounter
T23.531A	Corrosion of first degree of multiple right fingers (nail) not including thumb, initial encounter
T32.0	Corrosions involving less than 10% of body surface
Y92.218	Other school as place of occurrence of external cause
Y93.D9	Activity, other, involving arts and handicrafts
Y99.8	Other external cause status

Coding Note(s)

Corrosions are chemical burns that require identification of the chemical substance and the chemical substance is the first listed diagnosis. The chemical substance is found in the Table of Drugs and Chemicals. The correct code for an accidental corrosion is found in the column for poisoning, accidental (unintentional). Codes for drugs and chemicals are combination codes that identify the substance and the external cause or intent, so an additional external cause of injury code to identify the intent is not required. However, for the initial encounter only, codes should be assigned for the place of occurrence, activity, and external cause status when documented.

Example 2

Second Degree Burn of Lower Leg

ICD-10-CM Code/Documentation
T24.231-	Burn of second degree of right lower leg
T24.232-	Burn of second degree of left lower leg
T24.239-	Burn of second degree of unspecified lower leg

Documentation and Coding Example

Twenty-eight-year-old male presents to ED with a burn injury to lower left leg. Patient states he was deep frying a turkey in his backyard of his condominium when the fryer was bumped and hot oil spilled out onto his leg. On examination, this is a mildly obese Caucasian male who looks somewhat older than his stated age. He is wearing short pants and the injury is easily visualized. The burn extends from just below the knee to just above the ankle. The skin is intact, red appearing, with area of blistering over anterior aspect of lower leg and patchy areas of white over the remaining burned region. Patient denies much pain. Peripheral pulses present via Doppler. Temperature 97.4, HR 104, RR 16, BP 136/66. IV placed in left forearm, Lactated Ringers infusing. Blood drawn for CBC, electrolytes. Regional burn center agrees to accept patient, request wounds be covered with TransCyte if available, Xeroform gauze if not. Arrangement made for EMS ground transport. Wound dressed with Xeroform gauze. Transferred to transport stretcher, cardiac monitor shows NSR, pulse oximeter 99 % on 2 L O2 via nasal cannula. Report to EMS crew. Stable for 60-minute drive to burn center.

Impression: Second degree burn anterior aspect lower leg.

TBSA

5%.

Diagnosis Code(s)

T24.232A	Burn of second degree of left lower leg, initial encounter
T31.0	Burns involving less than 10% of body surface
X10.2XXA	Contact with fats and cooking oils, initial encounter
Y92.038	Other place in apartment as the place of occurrence of the external cause
Y93.G9	Activity, other involving cooking and grilling
Y99.8	Other external cause status

Dislocation of Acromioclavicular Joint

In ICD-10-CM, AC joint dislocation is a subcategory under category S43, Dislocation and sprain of joints and ligaments of shoulder girdle. In subcategory S43.1 Subluxation and dislocation of AC joint, injuries are specific to type, subluxation, or dislocation, and dislocation is further differentiated by the amount and the direction of the displacement. It may be difficult to translate the physician documentation into the correct code for AC joint subluxation and dislocation because the commonly used Allman and Tossy classification for injuries identified as Type I-III, and the Rockwood modification that added Types IV-VI, do not correlate exactly with the ICD-10-CM code descriptions.

Subluxation is an incomplete dislocation and may be described as a sprain or separation of the joint. There is only one subcategory for subluxation of the AC joint (S43.11-). Dislocation codes are reported when there is a complete dislocation of joint. Complete dislocation is further differentiated by the amount of displacement and the direction of the displacement of the AC joint structures. The six types of injuries described by the Allman-Tossy-Rockwood classification are as follows:

•Type I – Sprain of AC ligament only

•Type II – Injury to AC ligament and joint capsule with disrupted but intact coracoacromial ligament. Vertical subluxation of clavicle

•Type III – Disruption of AC ligament, joint capsule, and coracoacromial ligament. Complete AC joint dislocation with clavicle displaced superiorly and complete loss of contact between the clavicle and acromion. The coracoclavicular interspace is 25%-100% greater than the normal shoulder

•Type IV – Disruption of AC ligament, joint capsule, and coracoacromial ligament. Complete AC joint dislocation with clavicle displaced posteriorly into or through the trapezius muscle

•Type V - Disruption of AC ligament, joint capsule, and coracoacromial ligament. Complete AC joint dislocation with extreme superior elevation of the clavicle (100%-300%). Complete detachment of deltoid and trapezius from the distal clavicle

•Type VI - Disruption of AC ligament, joint capsule, and coracoacromial ligament. Complete AC joint dislocation with clavicle displaced inferior to acromion and coracoid process

Correlation between Allman-Tossy-Rockwood classification and ICD-10-CM codes are as follows:

•Type I – Report a code from subcategory S43.5- Sprain of acromioclavicular joint

•Type II – Report a code from subcategory S43.11 Subluxation of AC joint

•Type III – Report a code from subcategory S43.10 Unspecified dislocation of AC joint. Even though the code description is for an unspecified dislocation, it is also used to report other specified dislocations that do not fall into one of the other subcategories. Since a Type III dislocation results in superior displacement, but the coracoclavicular interspace is less than 100% when compared to the normal shoulder, no other AC joint dislocation applies

•Type IV – Report a code from subcategory S43.15 Posterior dislocation of AC joint

•Type V – Report either a code from subcategory S43.12 Dislocation of AC joint, 100%-200% displacement or subcategory S43.13 Dislocation of AC joint, greater than 200% displacement. If the amount of displacement as compared to the normal shoulder is not specified, query the physician

•Type VI – Report a code from subcategory S43.14 Inferior dislocation of AC joint.

Coding and Documentation Requirements

Identify type of AC joint injury:

•Sprain

•Subluxation

•Dislocation

–100%-200% (superior) displacement

–200% (superior) displacement

–Inferior

–Posterior

–Unspecified

Identify laterality:

•Right

•Left

•Unspecified

Identify episode of care:

•Initial encounter

•Subsequent encounter

•Sequela

Note: There is no 7^th character to classify an open subluxation/dislocation nor is there a separate code. If documented as an open dislocation a code from category S41.-Open wound of shoulder must also be added.

ICD-10-CM Code/Documentation
S43.101-	Unspecified dislocation of right acromioclavicular joint
S43.102-	Unspecified dislocation of left acromioclavicular joint
S43.109-	Unspecified dislocation of unspecified acromioclavicular joint
S43.111-	Subluxation of right acromioclavicular joint
S43.112-	Subluxation of left acromioclavicular joint
S43.119-	Subluxation of unspecified acromioclavicular joint
S43.121-	Dislocation of right acromioclavicular joint, 100%-200% displacement
S43.122-	Dislocation of left acromioclavicular joint, 100%-200% displacement
S43.129-	Dislocation of unspecified acromioclavicular joint, 100%-200% displacement
S43.131-	Dislocation of right acromioclavicular joint, greater than 200% displacement
S43.132-	Dislocation of left acromioclavicular joint, greater than 200% displacement
S43.139-	Dislocation of unspecified acromioclavicular joint, greater than 200% displacement
S43.141-	Inferior dislocation of right acromioclavicular joint
S43.142-	Inferior dislocation of left acromioclavicular joint
S43.149-	Inferior dislocation of unspecified acromioclavicular joint
S43.151-	Posterior dislocation of right acromioclavicular joint
S43.152-	Posterior dislocation of left acromioclavicular joint
S43.159-	Posterior dislocation of unspecified acromioclavicular joint
S43.50-	Sprain of unspecified acromioclavicular joint
S43.51-	Sprain of right acromioclavicular joint
S43.52-	Sprain of left acromioclavicular joint

Documentation and Coding Example

Twenty-three-year-old Black male employed as a gardener on a private estate presents to Urgent Care Clinic with a right shoulder injury sustained about 6 hours ago. He reports that he fell approximately 5 feet off a ladder while trimming hedges, landing on his outstretched right arm and hand. He describes a “popping” feeling in the shoulder followed by numbness in the arm and hand. He was able to move the extremity after a few minutes and the numbness subsided in approximately one hour, but the shoulder has continued to feel loose all day. PMH includes asthma for which he takes Singulair, Advair daily and Albuterol when needed and TB treated with INH seven years ago. On examination, this is a soft spoken, slightly built, thin young man. Temperature 97.4, HR 62, RR 14, BP 116/70. Alert and oriented x 3, PERRL, patient denies striking head, neck, or back in the fall. Heart rate regular without murmur, breath sounds have a few expiratory wheezes but otherwise clear and equal bilaterally. Left upper extremity is normal in appearance. Right clavicle has slight prominence but otherwise normal contour, there is no shoulder sag. Moderate point tenderness is localized over the AC joint which can be easily manipulated out of position. There are no obvious neurovascular deficits. X-rays obtained including AP and lateral views of shoulder, lateral projection of scapula and weight bearing view (AP projection w/15 lb. weight). No fractures visible and no obvious dislocation of clavicle or humerus.

Impression: Subluxation of right acromioclavicular joint. Treatment: Patient is fitted with a sling which can be worn for comfort. He is instructed to ice shoulder x 20 minutes, 3-4 x day and may continue with exercise/activity as tolerated. He is prescribed Ibuprofen 600 mg TID for pain. He will F/U with PMD in one week with possible referral to orthopedist and/or physical therapy for strengthening exercises if the right shoulder joint continues to feel loose.

Diagnosis Code(s)

S43.111A	Subluxation of right acromioclavicular joint, initial encounter
W11.XXXA	Fall on and from ladder, initial encounter
Y92.017	Garden or yard in single-family (private) house as the place of occurrence of the external cause
Y93.H2	Activity, gardening and landscaping
Y99.0	Civilian activity for income or pay

Coding Note(s)

Documentation of a Type II AC joint injury or partial dislocation would be reported with the code for subluxation.

Fracture of Skull

Fractures of the skull are captured with codes from subcategories S02.0- Fracture of vault of skull and S02.1- Fracture of base of skull (unspecified site of base of skull, fracture of the occiput or occipital condyle, orbital roof, and other specified fractures of the base of the skull which includes anterior, middle, or posterior fossa, sphenoid bone, temporal bone, and ethmoid and frontal sinus). Fractures of the orbital floor are reported in category S02.3- while orbital wall fractures are coded to S02.8-. A 7th character extension identifies the fracture as open or closed and identifies the episode of care. A second code from category S06 is required to capture any intracranial injury with or without loss of consciousness. Intracranial injury codes are much more specific as to the type of injury. In addition, when there is a loss of consciousness, the codes are much more specific as to the period of time and to the outcome—including survival with or without return to previous conscious level for loss of consciousness greater than 24 hours, or death due to intracranial injury or other cause prior to regaining consciousness. In addition to the fracture and intracranial injury codes, one or more supplementary codes may be required to capture elements of any documented coma using the Glasgow coma scale classification.

Coding and Documentation Requirements

Identify skull fracture site:

•Vault of skull, which includes

–Frontal bone

–Parietal bone

•Base of skull, which includes

–Anterior fossa

–Ethmoid sinus

–Frontal sinus

–Middle fossa

–Occipital bone

–Posterior fossa

–Sphenoid bone

–Temporal bone

•Orbital floor

•Orbital roof

•Orbital wall

–Lateral

–Medial

Identify laterality

•Right

•Left

•Unspecified side

Identify fracture as:

•Closed

•Open

Identify episode of care:

•Initial

•Subsequent

–With routine fracture healing

–With delayed fracture healing

–With nonunion of fracture

•Sequela

Identify nature of any intracranial injury:

•Concussion

•Cerebral edema, which includes

–Diffuse edema

–Focal edema

•Contusion/laceration

–Brainstem

–Cerebellum

–Cerebrum

»Right

»Left

»Unspecified site

•Diffuse traumatic brain injury

•Focal traumatic brain injury

•Hemorrhage

–Intracranial

»Brainstem

»Cerebellum

»Cerebrum, left

»Cerebrum, right

»Cerebrum, unspecified

–Epidural (extradural)

–Subarachnoid

–Subdural

•Other specified intracranial injury

–Internal carotid artery, intracranial portion

»Left

»Right

–Other specified intracranial injury

•Unspecified intracranial injury

Identify any loss of consciousness:

•No loss of consciousness

•30 minutes or less

•31 minutes to 59 minutes

•1 hour to 5 hours 59 minutes

•6 hours to 24 hours

•Greater than 24 hours

–With return to pre-existing conscious level

–Without return to pre-existing conscious level

•Any duration with death prior to regaining consciousness

–Death due to brain injury

–Death due to other cause

•Unspecified duration

Episode of care:

•Initial

•Subsequent

•Sequela

Coma Scale reporting requires the use of individual scores, if known. All three elements—eye opening, verbal response, and motor response must be known to use individual scores. If all three elements are not known, but Glasgow coma scale is documented, use the Glasgow coma scale total score.

Identify individual scores:

•Eyes open

–Never

–To pain

–To sound

–Spontaneous

•Best verbal response

–None

–Incomprehensible words

–Inappropriate words

–Confused conversation

–Oriented

•Best motor response

–None

–Extension

–Abnormal flexion

–Flexion withdrawal

–Localizes pain

–Obeys commands

Identify Glasgow coma scale total score:

•Glasgow score 13-15

•Glasgow score 9-12

•Glasgow score 3-8

Identify time/place of coma score obtained:

•In the field (EMT/ambulance)

•At arrival in emergency department

•At hospital admission

•24 hours or more after hospital admission

•Unspecified time

OR

•Other coma without documented Glasgow coma scale score or with partial score reported

Closed Fracture of Skull with Cerebral Edema

ICD-10-CM Code/Documentation
Fracture Skull Vault
S02.0XXA	Fracture of vault of skull, initial encounter for closed fracture
Traumatic Cerebral Edema/Loss of Consciousness
S06.1X0A	Traumatic cerebral edema without loss of consciousness, initial encounter
S06.1X1A	Traumatic cerebral edema with loss of consciousness ≤ 30 min, initial encounter
S06.1X2A	Traumatic cerebral edema with loss of consciousness 31 min to 59 min, initial encounter
S06.1X3A	Traumatic cerebral edema with loss of consciousness 1 hr. to 5 hrs. 59 min, initial encounter
S06.1X4A	Traumatic cerebral edema with loss of consciousness 6 hours to 24 hours, initial encounter
S06.1X5A	Traumatic cerebral edema with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
S06.1X6A	Traumatic cerebral edema with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
S06.1X7A	Traumatic cerebral edema with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness
S06.1X8A	Traumatic cerebral edema with loss of consciousness of any duration with death due to other cause prior to regaining consciousness
S06.1x9A	Traumatic cerebral edema with loss of consciousness of unspecified duration, initial encounter

Note 1: An initial encounter for an open fracture of vault of skull without mention of intracranial injury is reported with the same codes listed above except that the 7th character extension ‘A’ is replaced with a ‘B’ for initial encounter for open fracture.

Note 2: The 7th character ‘A’ for codes in category S06 indicates only that this is the initial encounter, not whether or not the injury is open or closed.

Closed Fracture of Skull with Cerebral Laceration/Contusion/Loss of Consciousness

ICD-10-CM Code/Documentation
Fracture Skull Vault
S02.0XXA	Fracture of vault of skull, initial encounter for closed fracture
Contusion/Laceration/Loss of Consciousness, Unspecified Duration
S06.319A	Contusion and laceration of right cerebrum with loss of consciousness of unspecified duration, initial encounter
S06.329A	Contusion and laceration of left cerebrum with loss of consciousness of unspecified duration, initial encounter
S06.339A	Contusion and laceration of unspecified cerebrum with loss of consciousness of unspecified duration, initial encounter
Contusion/Laceration/Without Loss of Consciousness
S06.310A	Contusion and laceration of right cerebrum without loss of consciousness, initial encounter
S06.320A	Contusion and laceration of left cerebrum without loss of consciousness, initial encounter
S06.330A	Contusion and laceration of unspecified cerebrum without loss of consciousness, initial encounter
Contusion/Laceration/Loss of Consciousness Under 1 Hour
S06.311A	Contusion and laceration of right cerebrum with loss of consciousness ≤ 30 min, initial encounter
S06.312A	Contusion and laceration of right cerebrum with loss of consciousness 31 min to 59 min, initial encounter
S06.321A	Contusion and laceration of left cerebrum with loss of consciousness ≤ 30 min, initial encounter
S06.322A	Contusion and laceration of left cerebrum with loss of consciousness 31 min to 59 min, initial encounter
S06.331A	Contusion and laceration of unspecified cerebrum with loss of consciousness ≤ 30 min, initial encounter
S06.332A	Contusion and laceration of unspecified cerebrum with loss of consciousness 31 min to 59 min, initial encounter
Contusion/Laceration/Loss of Consciousness 1-24 Hours
S06.313A	Contusion and laceration of right cerebrum with loss of consciousness 1 hr. to 5 hrs. 59 min, initial encounter
S06.314A	Contusion and laceration of right cerebrum with loss of consciousness 6 hrs. to 24 hrs., initial encounter
S06.323A	Contusion and laceration of left cerebrum with loss of consciousness 1 hr. to 5 hrs. 59 min, initial encounter
S06.324A	Contusion and laceration of left cerebrum with loss of consciousness 6 hrs. to 24 hrs., initial encounter
S06.333A	Contusion and laceration of unspecified cerebrum with loss of consciousness 1 hr. to 5 hrs. 59 min, initial encounter
S06.334A	Contusion and laceration of unspecified cerebrum with loss of consciousness 6 hrs. to 24 hrs., initial encounter
Contusion/Laceration/Loss of Consciousness, More Than 24 Hours
S06.315A	Contusion and laceration of right cerebrum with loss of consciousness greater than 24 hours with return to preexisting conscious level, initial encounter
S06.325A	Contusion and laceration of left cerebrum with loss of consciousness greater than 24 hours with return to preexisting conscious level, initial encounter
S06.335A	Contusion and laceration of unspecified cerebrum with loss of consciousness greater than 24 hours with return to preexisting conscious level, initial encounter
S06.316A	Contusion and laceration of right cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
S06.326A	Contusion and laceration of left cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
S06.336A	Contusion and laceration of unspecified cerebrum with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter

Note 1: An initial encounter for an open fracture of vault of skull with cerebral laceration and contusion is reported with the same codes listed above except that the 7th character extension ‘A’ is replaced with a ‘B’ for initial encounter for open fracture.

Note 2: The 7th character ‘A’ for codes in category S06 indicates only that this is the initial encounter, not whether or not the injury is open or closed.

Note 3: There are additional contusion and laceration codes that reflect death either due to the brain injury or other brain injury. These codes are:

S06.017A	Contusion and laceration of right cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
S06.018A	Contusion and laceration of right cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
S06.027A	Contusion and laceration of left cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
S06.028A	Contusion and laceration of left cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
S06.037A	Contusion and laceration of unspecified cerebrum with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
S06.038A	Contusion and laceration of unspecified cerebrum with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter

Closed Fracture of Skull with Subarachnoid, Subdural, and Extradural Hemorrhage

ICD-10-CM Code/Documentation
Fracture Skull Vault
S02.0XXA	Fracture of vault of skull, initial encounter for closed fracture
Hemorrhage/Loss of Consciousness, Unspecified Duration
S06.4X9A	Epidural hemorrhage with loss of consciousness of unspecified duration, initial encounter
S06.5X9A	Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter
S06.6X9A	Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, initial encounter
Hemorrhage/Without Loss of Consciousness
S06.4X0A	Epidural hemorrhage without loss of consciousness, initial encounter
S06.5X0A	Traumatic subdural hemorrhage without loss of consciousness, initial encounter
S06.6X0A	Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter
Hemorrhage/Loss of Consciousness ≤ 30 Minutes
S06.4X1A	Epidural hemorrhage with loss of consciousness ≤ 30 min, initial encounter
S06.5X1A	Traumatic subdural hemorrhage with loss of consciousness ≤ 30 min, initial encounter
S06.6X1A	Traumatic subarachnoid hemorrhage with loss of consciousness ≤ 30 min, initial encounter
Hemorrhage/Loss of Consciousness, 31-59 Minutes
S06.4X2A	Epidural hemorrhage with loss of consciousness 31 min to 59 min, initial encounter
S06.5X2A	Traumatic subdural hemorrhage with loss of consciousness 31 min to 59 min, initial encounter
S06.6X2A	Traumatic subarachnoid hemorrhage with loss of consciousness 31 min to 59 min, initial encounter
Hemorrhage/Loss of Consciousness, 1 Hr - 5 Hrs. 59 Min
S06.4X3A	Epidural hemorrhage with loss of consciousness 1 hr. to 5 hrs. 59 min, initial encounter
S06.5X3A	Traumatic subdural hemorrhage with loss of consciousness 1 hr. to 5 hrs. 59 min, initial encounter
S06.6X3A	Traumatic subarachnoid hemorrhage with loss of consciousness 1 hr. to 5 hrs. 59 min, initial encounter
Hemorrhage/Loss of Consciousness, 6-24 Hours
S06.4X4A	Epidural hemorrhage with loss of consciousness 6 hrs. to 24 hrs., initial encounter
S06.5X4A	Traumatic subdural hemorrhage with loss of consciousness 6 hrs. to 24 hrs., initial encounter
S06.6X4A	Traumatic subarachnoid hemorrhage with loss of consciousness 6 hrs. to 24 hrs., initial encounter
Hemorrhage/Loss of Consciousness, More Than 24 Hours
S06.4X5A	Epidural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
S06.5X5A	Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
S06.6X5A	Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours with return to preexisting conscious level, initial encounter
S06.4X6A	Epidural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
S06.5X6A	Traumatic subdural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
S06.6X6A	Traumatic subarachnoid hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter

Note 1: An initial encounter for an open fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage is reported with the same codes listed above except that the 7th character extension ‘A’ is replaced with a ‘B’ for initial encounter for open fracture.

Note 2: The 7th character ‘A’ for codes in category S06 indicates only that this is the initial encounter, not whether or not the injury is open or closed.

Note 3: There are ICD-10-CM epidural hemorrhage, traumatic subarachnoid hemorrhage, and traumatic subdural hemorrhage codes that reflect death either due to the brain injury or other brain injury. These codes are:

S06.4X7A	Epidural hemorrhage with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
S06.4X8A	Epidural hemorrhage with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
S06.5X7A	Traumatic subdural hemorrhage with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
S06.5X8A	Traumatic subdural hemorrhage with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter
S06.6X7A	Traumatic subarachnoid hemorrhage with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial encounter
S06.6X8A	Traumatic subarachnoid hemorrhage with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial encounter

Documentation and Coding Example

Sixteen-year-old Caucasian male transported to local ED via ambulance after he was found unresponsive at home by his mother. Patient has a fresh 4 cm x 5 cm hematoma on left temporal area. Mother states her son was surfing earlier in the day and was hit in the head by his board. He continued surfing for approximately 1 hour following the accident and drove himself home. He was alert and oriented all morning, only complaining of a headache, taking ibuprofen at 10 AM. He appeared to be sleeping at 1 PM when mother left to do errands and she was unable to arouse him when she returned 2 hours later. On examination, this is a well-developed, well-nourished, adolescent male. Temperature 97.4, HR 66, RR 12, BP 88/50. Neurological examination reveals no spontaneous eye opening or response to verbal commands, there is withdrawal from painful stimuli. Score = 6 on Glasgow Coma Scale. Call placed to Children’s Hospital Trauma Center and life flight team dispatched. ETA 22 minutes. NSR on cardiac monitor. O2 saturation 92% by pulse oximetry, O2 started at 2 L/m via non-rebreather mask. HOB elevated 30%. IV line placed right forearm, LR infusing. Blood drawn for CBC, platelets, electrolytes, PT, PTT, type and hold and sent to lab. Bladder can be palpated above the pubic bone, Foley catheter placed without difficulty, 600 cc clear yellow urine returned.

Transport Team Note: Arrived in ED at 4:13 PM. Baseline lab tests all within normal limits. ABG drawn pH 7.32, pCO2 51, HCO3 25, pO2 88 %, SaO2 96 %. Patient intubated without difficulty, hand ventilated by RT. Transferred to life flight stretcher, on monitors, stable for transport. All consents obtained, parents following in private car. ETA Children’s Hospital 17 minutes with neurosurgical team assembled and ready for patient. Uneventful helicopter transport. Patient taken directly from heliport to CT. Care assumed by neurosurgical team and radiology staff.

Neurosurgical Note: CT scan reveals a linear fracture of the left parietal bone with large subdural hematoma. Patient taken to OR at 6:15 PM where a craniotomy was performed under general anesthesia. Hematoma evacuated and patient taken to Neurosurgical ICU with arterial line, CVP line, ICP catheter. Mannitol drip, prophylactic antibiotics, and anti-seizure medications.

Neurosurgical ICU Note: Patient arrived in unit at 9:50 PM. VSS stable on monitors. CVP, ICP pressures WNL. Patient comfortably sedated, taking spontaneous breaths on ventilator. Parents in to visit. Opens eyes to parents’ voices, localizes painful stimuli, unable to vocalize due to intubation, Glasgow coma scale=9. Continued progress throughout night, extubated at 6 AM. Alert, recognizes parents, oriented to person only, last memory he has is surfing.

Discharge Note: Patient made an excellent physical recovery from surgery and is discharged on post-op day 5, wound staples removed prior to discharge. He has no residual weakness or visual deficits. He still has no memory of the time between surfing and waking up in the ICU. Patient weaned from anti-seizure medications with normal EEG. He is discharged without medications and will be seen in Neurosurgical Clinic in 2 days.

Discharge diagnosis:

•Linear skull fracture, left parietal bone

•Large subdural hematoma

•Total duration of loss of consciousness estimated at 6-7 hours

Diagnosis Code(s)

Note: Codes are for inpatient services at 2nd facility

S06.5X4A	Traumatic subdural hemorrhage with loss of consciousness 6 hours to 24 hours, initial encounter
S02.0XXA	Fracture of vault of skull, initial encounter for closed fracture
R40.2134	Coma scale, eyes open to sound, 24 hours or more after hospital admission
R40.2214	Coma scale, best verbal response, none, 24 hours or more after hospital admission
R40.2354	Coma scale, best motor response, localizes pain, 24 hours or more after hospital admission
W21.89XA	Striking against or struck by other sports equipment, initial encounter
Y92.832	Beach as the place of occurrence of the external cause
Y93.18	Activity, surfing, windsurfing and boogie boarding
Y99.8	Other external cause status

Coding Note(s)

In ICD-10-CM, there is a sequencing note indicating that the intracranial injury is coded first. Glasgow coma scale codes are reported additionally with the fracture of skull (S02.-) and/or intracranial injury (S06.-) reported first. Both facilities and all physicians and ancillary service providers will report skull fracture codes with 7th character ‘A’ for initial episode of care because the services described above are related to the acute phase of the injury. The patient has a hematoma but no open wound of the head is documented, so the skull fracture is classified as a closed fracture which is also captured by the 7th character ‘A’. The traumatic subdural hemorrhage is also reported with 7th character ‘A’. There is documentation related to each element of the coma scale so each of the three components are coded rather than assigning the code for the Glasgow coma scale total score from subcategory R40.24. If only the total score had been reported, code R40.242 Glasgow coma scale score 9-12 would be assigned instead of the individual coma scores for eyes open, best verbal response, and best motor response.

Fracture of Cervical Vertebra with Spinal Cord Injury

Fractures of the cervical vertebra or other parts of the neck are reported with codes from category S12. If the fracture is associated with a cervical spinal cord injury, a code from category S14 is also required, and the code from category S14 is listed first. Fracture and spinal cord injury codes require the specific level of the fracture (C1, C2, C3, C4, C5, C6, C7). Associated spinal cord injuries require documentation of the type and extent of the injury to include incomplete lesion, Brown-Séquard syndrome, and a subcategory for other specified incomplete lesion.

Coding and Documentation Requirements

Fracture of cervical spine

Identify level/site of cervical spine fracture:

•C1

•C2

•C3

•C4

•C5

•C6

•C7

Identify type of fracture:

•For C1

–Burst fracture

»Stable

»Unstable

»Posterior arch

»Lateral mass

»Other specified fracture

»Unspecified fracture

•For C2

–Dens fracture

»Type II anterior displaced

»Type II posterior displaced

»Type II nondisplaced

»Other displaced

»Other nondisplaced

–Traumatic spondylolisthesis

»Type III

»Other specified traumatic spondylolisthesis

»Unspecified traumatic spondylolisthesis

–Other specified fracture

–Unspecified fracture

•For C3-C7

–Traumatic spondylolisthesis

»Type III

»Other specified traumatic spondylolisthesis

»Unspecified traumatic spondylolisthesis

–Other specified fracture

–Unspecified fracture

Identify fracture as nondisplaced or displaced as needed:

•Displaced

•Nondisplaced

Note: Some specific types of fractures are by definition either nondisplaced or displaced so this qualifier is not always required.

Identify fracture as:

•Closed

•Open

Identify episode of care:

•Initial

•Subsequent

–With routine healing of fracture

–With delayed healing of fracture

–With nonunion of fracture

•Sequela

Spinal Cord Injury (if present)

Identify type of spinal cord injury:

•Anterior cord syndrome

•Brown-Séquard syndrome

•Central cord syndrome

•Complete lesion of cord

•Concussion/edema

•Other specified incomplete lesion of spinal cord

•Unspecified spinal cord injury

Identify highest level of cervical spinal cord injury:

•C1

•C2

•C3

•C4

•C5

•C6

•C7

•C8

•Unspecified level

Identify episode of care:

•Initial

•Subsequent

•Sequela

C5 Fracture with Spinal Cord Injury

ICD-10-CM Code/Documentation
C5 Vertebral Fracture
S12.400A	Unspecified displaced fracture of fifth cervical vertebrae, initial encounter for closed fracture
S12.401A	Unspecified nondisplaced fracture of fifth cervical vertebra, initial encounter for closed fracture
S12.430A	Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.431A	Unspecified traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.44xA	Type III traumatic spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.450A	Other traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.451A	Other traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.490A	Other displaced fracture of fifth cervical vertebra, initial encounter for closed fracture
S12.491A	Other nondisplaced fracture of fifth cervical vertebra, initial encounter for closed fracture
C5 Spinal Cord Injury
S14.105A	Unspecified injury at C5 level of cervical spinal cord, initial encounter
C5 Vertebral Fracture
S12.400A	Unspecified displaced fracture of fifth cervical vertebrae, initial encounter for closed fracture
S12.401A	Unspecified nondisplaced fracture of fifth cervical vertebra, initial encounter for closed fracture
S12.430A	Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.431A	Unspecified traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.44xA	Type III traumatic spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.450A	Other traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.451A	Other traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.490A	Other displaced fracture of fifth cervical vertebra, initial encounter for closed fracture
S12.491A	Other nondisplaced fracture of fifth cervical vertebra, initial encounter for closed fracture
C5 Spinal Cord Injury
S14.115A	Complete lesion at C5 level of cervical spinal cord, initial encounter
S12.451A	Other traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.490A	Other displaced fracture of fifth cervical vertebra, initial encounter for closed fracture
S12.491A	Other nondisplaced fracture of fifth cervical vertebra, initial encounter for closed fracture
C5 Spinal Cord Injury
S14.135A	Anterior cord syndrome at C5 level of cervical spinal cord, initial encounter
C5 Vertebral Fracture
S12.400A	Unspecified displaced fracture of fifth cervical vertebrae, initial encounter for closed fracture
S12.401A	Unspecified nondisplaced fracture of fifth cervical vertebra, initial encounter for closed fracture
S12.430A	Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.431A	Unspecified traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.44xA	Type III traumatic spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.450A	Other traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.451A	Other traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.490A	Other displaced fracture of fifth cervical vertebra, initial encounter for closed fracture
S12.491A	Other nondisplaced fracture of fifth cervical vertebra, initial encounter for closed fracture
C5 Spinal Cord Injury
S14.125A	Central cord syndrome at C5 level of cervical spinal cord, initial encounter
C5 Vertebral Fracture
S12.400A	Unspecified displaced fracture of fifth cervical vertebrae, initial encounter for closed fracture
S12.401A	Unspecified nondisplaced fracture of fifth cervical vertebra, initial encounter for closed fracture
S12.430A	Unspecified traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.431A	Unspecified traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.44xA	Type III traumatic spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.450A	Other traumatic displaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.451A	Other traumatic nondisplaced spondylolisthesis of fifth cervical vertebra, initial encounter for closed fracture
S12.490A	Other displaced fracture of fifth cervical vertebra, initial encounter for closed fracture
S12.491A	Other nondisplaced fracture of fifth cervical vertebra, initial encounter for closed fracture
C5 Spinal Cord Injury
S14.0XXA	Concussion and edema of cervical spinal cord, initial encounter
S14.145A	Brown-Séquard syndrome at C5 level of spinal cord, initial encounter
S14.155A	Other incomplete lesion at C5 level of spinal cord, initial encounter

Documentation and Coding Example

Patient is a thirty-eight-year-old Hispanic female brought to ED following MVA. Patient was an unrestrained passenger in the rear seat of a car struck head on by another car at a high rate of speed. She was completely ejected and found semi-conscious with no spontaneous movement on the pavement approximately 50 feet from the crash site on I-15. IV started in left antecubital, C-spine immobilized, placed on backboard and transported via ambulance to ED. On examination, this is a mildly obese, middle-aged female. She has abrasions and contusions on face, upper right shoulder, and right thoracic region of back consistent with sliding on asphalt. Patient opens her eyes on command and can state her name. She is able to recall being in a car accident, is not able to provide any medical history. Vocal quality is weak and breathless. PERRL. HR 50, RR 20, BP 84/50. O2 Sat. 93% on O2 4 L/m via mask. Color pale, skin diaphoretic. Breath sounds clear, shallow. Apical pulse irregular, peripheral pulses weak. SR on monitor with frequent PVCs. Abdomen soft, non-distended with poor tone. Bedside US reveals no free fluid in peritoneum. Foley catheter placed and returns clear yellow urine. Patient has no sensory awareness from shoulders down and no spontaneous muscle movement. She does complain of pain in her face, jaw, and neck. Findings are consistent with traumatic injury to the neck and spinal cord.

C-spine x-ray reveals a fracture of C5 with small fragment anteriorly and angulation of C5-C6 with displacement of C5 posteriorly. Neurosurgical team assembled and ready to assume care. CT reveals severe axial loading with propulsion of a teardrop bone fragment anteriorly and larger portion of the bone resting posterior against the spinal cord. MRI is consistent with soft tissue injury both anterior and posterior to the spinal cord. Patient is taken to surgery for decompression of spinal cord and stabilization of fracture.

Surgical ICU Note: Patient admitted from OR following decompression laminectomy, intubated, on ventilator, neck immobilized with hard cervical collar. Arterial line patent left wrist, peripheral IV lines in left antecubital and right hand. Abrasions cleaned in OR are covered with Xeroform gauze. There is no voluntary muscle movement and flaccid muscle tone from shoulders to toes. Weaned from ventilator on day four.

Step Down Unit Note: Transferred 5 days with one peripheral IV line. Patient has very flat affect, she reportedly lost all family members in the accident. Reflexes are consistent with a complete spinal cord injury at C5. She is able to perform a very weak shoulder shrug bilaterally but has no sensation or movement below that level. Patient receiving PT, OT, and ST.

Diagnosis Code(s)

S14.115A	Complete lesion at C5 level of cervical spinal cord, initial encounter
S12.490A	Other displaced fracture of fifth cervical vertebrae, initial encounter for closed fracture
S00.81XA	Abrasion of other part of head, initial encounter
S00.83XA	Contusion of other part of head, initial encounter
S20.221A	Contusion of right back wall of thorax, initial encounter
S20.411A	Abrasion of right back wall of thorax, initial encounter
S40.011A	Contusion of right shoulder, initial encounter
S40.211A	Abrasion of right shoulder, initial encounter
V43.62XA	Car passenger injured in collision with other type car in traffic accident, initial encounter
Y92.411	Interstate highway as the place of occurrence of the external cause

Coding Note(s)

There is a note under category S14 to code also any transient paralysis (R29.5). Code R29.5 would not be reported as the patient has sustained an injury resulting in permanent paralysis.

Fracture of Dorsal (Thoracic) Vertebra

Similar to cervical spine fractures both the level of the fracture and the type of fracture must be specified. In addition, the fracture must be documented as open or closed and the episode of care must be known. For follow-up care, healing must be documented as routine, delayed, or with nonunion.

Coding and Documentation Requirements

Identify level of vertebral fracture:

•T1

•T2

•T3

•T4

•T5-T6

•T7-T8

•T9-T10

•T11-T12

Identify type of fracture:

•Burst

–Stable

–Unstable

•Wedge compression

•Other specified type of fracture

•Unspecified type of fracture

Identify fracture:

•Closed

•Open

Identify episode of care:

•Initial

•Subsequent

–With routine healing of fracture

–With delayed healing of fracture

–With nonunion of fracture

•Sequela

Fracture of T11-T12 Vertebra

ICD-10-CM Code/Documentation
Closed fracture
S22.080A	Wedge compression fracture of T11-T12 vertebra, initial encounter for closed fracture
S22.081A	Stable burst fracture of T11-T12 vertebra, initial encounter for closed fracture
S22.082A	Unstable burst fracture of T11-T12 vertebra, initial encounter for closed fracture
S22.088A	Other fracture of T11-T12 vertebra, initial encounter for closed fracture
S22.089A	Unspecified fracture of T11-T12 vertebra, initial encounter for closed fracture
Open fracture
S22.080B	Wedge compression fracture of T11-T12 vertebra, initial encounter for open fracture
S22.081B	Stable burst fracture of T11-T12 vertebra, initial encounter for open fracture
S22.082B	Unstable burst fracture of T11-T12 vertebra, initial encounter for open fracture
S22.088B	Other fracture of T11-T12 vertebra, initial encounter for open fracture
S22.089V	Unspecified fracture of T11-T12 vertebra, initial encounter for open fracture

Documentation and Coding Example

Thirty-nine-year-old male presents to ED with c/o moderate to severe pain in his back after falling approximately 15 feet from a boulder while rock climbing. Accident occurred approximately 2 hours ago. Patient is a well-developed, well-nourished male who looks younger than his stated age. He is muscular and very tan. He states he is a professional guide leading hiking tours and rock climbing expeditions. The accident today occurred in his leisure time on a familiar rock face and was witnessed by friends. As he descended from the top of the rock, his equipment malfunctioned and he dropped rapidly, landing with a hard jolt upright on both legs. He felt an immediate sharp pain in the mid back which is relieved somewhat by lying flat. He denies pain in his hips, knees, or ankles and was able to hike approximately ½ mile to a vehicle. On examination: Temperature 99 degrees, HR 72, RR 12, BP 114/60. Skin warm, slightly diaphoretic, outdoor temperature is in upper 80s. O2 saturation on RA 96%. PERRL, oriented x 3. No cervical spine tenderness and cranial nerves are grossly intact. Motor and sensory function is intact to upper extremities. Breath sounds clear and equal bilaterally, HR regular, no murmur or muffling of heart sounds appreciated. No visual deformities to spine but there is exquisite tenderness with muscle guarding at level of T10 to L4. There is no sign of crepitus. He has limited ROM when attempting flexion, extension, and rotation of spine due to pain. There are no neurological deficits in lower extremities. IV started in left forearm, D5 LR infusing. Medicated for pain with MS 2 mg IV push with good relief. AP and lateral spine x-rays reveal a possible wedge compression fracture at T12. CT confirms wedge compression fracture involving the anterior column at T12. Orthopedic consult obtained. Patient fitted with TLSO brace and discharged home with oral narcotic pain medication and instructions to schedule a follow-up in orthopedic clinic in 1 week.

Diagnosis Code(s)

S22.080A	Wedge compression fracture of T11-T12 vertebra, initial encounter for closed fracture
W17.89XA	Other fall from one level to another, initial encounter
Y93.31	Activity, mountain climbing, rock climbing, and wall climbing
Y92.838	Other recreation area as place of occurrence of the external cause
Y99.8	Other external cause status

Coding Note(s)

Y99.8 Other external cause status which includes leisure activity, is used instead of Y99.0 Civilian activity done for income or pay because even though the patient works as a guide on rock climbing expeditions, he incurred this injury during his leisure time not while he was working.

Fracture of Humerus, Surgical Neck

Fractures of the upper end of the humerus are classified as surgical neck fractures, greater tuberosity fractures, lesser tuberosity fractures, torus fractures, other specified fractures of the upper end of the humerus, and unspecified fractures. Surgical neck fractures of the proximal or upper end of the humerus are further classified using the Neer system. The proximal humerus is divided into four parts—the humeral head, greater tubercle, lesser tubercle, and diaphysis or shaft. These four parts are separated by epiphyseal lines, also called growth plates which were present when the bones were still growing during the developmental years. The surgical neck is at the narrowest aspect of the humerus just below the tubercles. When the proximal humerus is fractured, it typically occurs at the surgical neck and along one or more of the three epiphyseal lines. The proximal humerus may fracture into 2, 3, or 4 parts at the surgical neck which is why surgical neck fractures are designated as 2-part, 3-part, or 4-part fractures.

The classification of the fracture is based upon the number of fragments and whether there is separation or angulation of the fragments. A fracture part is considered displaced if it is angulated more than 45^o or displaced greater than 1 cm. A fracture that is not displaced <1cm and angulated < 45^o regardless of how many pieces is considered a one-part fracture. All other Neer classifications are based upon the total number of fractures and the number of fractures that are displaced or angulated. For example, a 2-part fracture can be 2-4 parts with one of those parts being displaced or angulated. A three-part fracture can be 3-4 parts with two of the parts being displaced or angulated.

Coding and Documentation Requirements

Identify site/type:

•Greater tuberosity

•Lesser tuberosity

•Surgical neck

–2-part

–3-part

–4-part

–Unspecified type surgical neck fracture

•Torus fracture

•Other specified site, which includes

–Anatomical neck

–Articular head

•Unspecified site/type fracture of upper end of humerus

Identify fracture status:

•Displaced

•Nondisplaced

Note: Some fracture types are by definition displaced or nondisplaced and codes for these types of fractures do not require documentation as displaced/nondisplaced.

Identify laterality:

•Right

•Left

•Unspecified

Identify fracture as:

•Closed

•Open

Identify episode of care:

•Initial encounter

•Subsequent encounter

–With routine healing

–With delayed healing

–With nonunion

–With malunion

•Sequela

Surgical Neck Fracture, Initial Encounter, Open and Closed Fractures

ICD-10-CM Code/Documentation
Closed Fracture
Unspecified Surgical Neck Fracture
S42.211A	Unspecified displaced fracture of surgical neck of right humerus, initial encounter for closed fracture
S42.212A	Unspecified displaced fracture of surgical neck of left humerus, initial encounter for closed fracture
S42.213A	Unspecified displaced fracture of surgical neck of unspecified humerus, initial encounter for closed fracture
S42.214A	Unspecified nondisplaced fracture of surgical neck of right humerus, initial encounter for closed fracture
S42.215A	Unspecified nondisplaced fracture of surgical neck of left humerus, initial encounter for closed fracture
S42.216A	Unspecified nondisplaced fracture of surgical neck of unspecified humerus, initial encounter for closed fracture
2-Part Fracture
S42.221A	2-part displaced fracture of surgical neck of right humerus, initial encounter for closed fracture
S42.222A	2-part displaced fracture of surgical neck of left humerus, initial encounter for closed fracture
S42.223A	2-part displaced fracture of surgical neck of unspecified humerus, initial encounter for closed fracture
S42.224A	2-part nondisplaced fracture of surgical neck of right humerus, initial encounter for closed fracture
S42.225A	2-part nondisplaced fracture of surgical neck of left humerus, initial encounter for closed fracture
S42.226A	2-part nondisplaced fracture of surgical neck of unspecified humerus, initial encounter for closed fracture
3-Part Fracture
S42.231A	3-part fracture of surgical neck of right humerus, initial encounter for closed fracture
S42.232A	3-part fracture of surgical neck of left humerus, initial encounter for closed fracture
S42.239A	3-part fracture of surgical neck of unspecified humerus, initial encounter for closed fracture
4-Part Fracture
S42.241A	4-part fracture of surgical neck of right humerus, initial encounter for closed fracture
S42.242A	4-part fracture of surgical neck of left humerus, initial encounter for closed fracture
S42.249A	4-part fracture of surgical neck of unspecified humerus, initial encounter for closed fracture
Open Fracture
Unspecified Fracture
S42.211B	Unspecified displaced fracture of surgical neck of right humerus, initial encounter for open fracture
S42.212B	Unspecified displaced fracture of surgical neck of left humerus, initial encounter for open fracture
S42.213B	Unspecified displaced fracture of surgical neck of unspecified humerus, initial encounter for open fracture
S42.214B	Unspecified nondisplaced fracture of surgical neck of right humerus, initial encounter for open fracture
S42.215B	Unspecified nondisplaced fracture of surgical neck of left humerus, initial encounter for open fracture
S42.216B	Unspecified nondisplaced fracture of surgical neck of unspecified humerus, initial encounter for open fracture
2-Part Fracture
S42.221B	2-part displaced fracture of surgical neck of right humerus, initial encounter for open fracture
S42.222B	2-part displaced fracture of surgical neck of left humerus, initial encounter for open fracture
S42.223B	2-part displaced fracture of surgical neck of unspecified humerus, initial encounter for open fracture
S42.224B	2-part nondisplaced fracture of surgical neck of right humerus, initial encounter for open fracture
S42.225B	2-part nondisplaced fracture of surgical neck of left humerus, initial encounter for open fracture
S42.226B	2-part nondisplaced fracture of surgical neck of unspecified humerus, initial encounter for open fracture
3-Part Fracture
S42.231B	3-part fracture of surgical neck of right humerus, initial encounter for open fracture
S42.232B	3-part fracture of surgical neck of left humerus, initial encounter for open fracture
S42.239B	3-part fracture of surgical neck of unspecified humerus, initial encounter for open fracture
4-Part Fracture
S42.241B	4-part fracture of surgical neck of right humerus, initial encounter for open fracture
S42.242B	4-part fracture of surgical neck of left humerus, initial encounter for open fracture
S42.249B	4-part fracture of surgical neck of unspecified humerus, initial encounter for open fracture

Documentation and Coding Example

Patient is a ninety-three-year-old Chinese female who comes reluctantly to ED accompanied by her family to evaluate an injury to her left arm. Patient speaks only Mandarin and her grandson serves as translator. Patient lives alone and is in overall good health. Grandson states the patient tripped over a box at home the day before, falling onto her left arm but was able to get up off the floor and go about her normal routine. Patient has immobilized her own arm by using a scarf to keep it tight to her body. HR 60, RR 12, BP 90/62. On examination, this is a very thin, frail appearing elderly woman. PERRL, neck supple. Right upper extremity is normal appearing with intact sensation and ROM. Left arm has ecchymosis extending the length of the arm, through the shoulder and 6-8 cm into the chest wall. Tenderness and swelling are appreciated in the upper arm and shoulder. No crepitus appreciated in arm or chest. Sensation intact to deltoid muscle and distally to fingers. ROM intact in fingers, wrist but decreased due to pain in elbow and shoulder. Breath sounds clear and equal bilaterally, HR regular, abdomen soft, non-tender. Lower extremities have good strength and ROM. Blood drawn for CBC, electrolytes, coagulation studies. Neer trauma series obtained for left upper extremity including AP and lateral films in scapular plane and axillary views with results consistent for a 3-part (possibly 4-part) fracture of the proximal humerus. AP and lateral chest films to R/O rib/chest trauma are WNL. CT shows a 3-part fracture. Patient evaluated by orthopedic service and decision made with family to treat with immobilization as an outpatient. Immobilizer applied, patient refuses a prescription for pain medication. She will be re-evaluated in orthopedic clinic in 2 days, if fracture remains stable she can begin PT.

Diagnosis Code(s)

S42.232A	3-part fracture of surgical neck of left humerus, initial encounter for closed fracture
W18.09XA	Striking against other object with subsequent fall, initial encounter
Y92.009	Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause

Coding Note(s)

While the documentation does not specifically indicate that the fracture is closed, from the documentation it is evident that there is no open injury at the fracture site. In addition, when a fracture is not documented as open or closed the default is closed.

Fracture Radius/Ulna Shaft

Fractures of the radius and ulna are classified by the type of fracture, such as greenstick, transverse, or oblique, then by whether the fracture is displaced or nondisplaced, and lastly by which arm (right, left) is involved. The 7th character captures whether the fracture is open or closed and for open fractures the 7th character also captures the Gustilo classification. When both the radius and ulna are fractured, two codes are assigned as there are no combination codes for fractures of the radius and ulna together. There are however combination codes for specific fracture patterns that include a fracture of the radius with an associated subluxation or dislocation of the distal radioulnar joint (Galeazzi) as well as for a Monteggia fracture pattern which is a fracture of the ulnar shaft with a dislocation of the radial head. Because these are combination codes defining both the fracture and dislocation, a separate dislocation code would not also be assigned.

Coding and Documentation Requirements

Radial shaft fractures

Identify type of radial shaft fracture:

•Bent bone

•Comminuted

•Galeazzi’s fracture

•Greenstick

•Oblique

•Segmental

•Spiral

•Transverse

•Other specified type of radial shaft fracture

•Unspecified

Identify fracture status:

•Displaced

•Nondisplaced

Note: Some fracture types are by definition displaced or nondisplaced and codes for these types of fractures do not require documentation as displaced/nondisplaced.

Identify laterality:

•Right

•Left

•Unspecified

Identify fracture as:

•Closed

•Open

–Gustilo Type I, II or open, but not otherwise specified (NOS)

–Gustilo Type IIIA, IIIB, IIIC

Identify episode of care:

•Initial encounter

•Subsequent encounter

–With routine healing

–With delayed healing

–With nonunion

–With malunion

•Sequela

Ulnar shaft fractures

Identify type of ulnar shaft fracture:

•Bent bone

•Comminuted

•Greenstick

•Monteggia’s fracture

•Oblique

•Segmental

•Spiral

•Transverse

•Other specified type of radial shaft fracture

•Unspecified

Identify fracture status:

•Displaced

•Nondisplaced

Note: Some fracture types are by definition displaced or nondisplaced and codes for these types of fractures do not require documentation as displaced/nondisplaced.

Identify laterality:

•Right

•Left

•Unspecified

Identify fracture as:

•Closed

•Open

–Gustilo Type I, II or open but not otherwise specified (NOS)

–Gustilo Type IIIA, IIIB, IIIC

Identify episode of care:

•Initial encounter

•Subsequent encounter

»With routine healing

»With delayed healing

»With nonunion

»With malunion

•Sequela

Closed Fracture of Radius and/or Ulna

ICD-10-CM Code/Documentation
Unspecified Forearm Fracture
S52.90xA	Unspecified fracture of unspecified forearm, initial encounter for closed fracture
S52.91xA	Unspecified fracture of right forearm, initial encounter for closed fracture
S52.92xA	Unspecified fracture of left forearm, initial encounter for closed fracture
Radius Shaft
Unspecified Fracture
S52.301A	Unspecified fracture of shaft of right radius, initial encounter for closed fracture
S52.302A	Unspecified fracture of shaft of left radius, initial encounter for closed fracture
S52.309A	Unspecified fracture of shaft of unspecified radius, initial encounter for closed fracture
Greenstick Fracture
S52.311A	Greenstick fracture of shaft of radius, right arm, initial encounter for closed fracture
S52.312A	Greenstick fracture of shaft of radius, left arm, initial encounter for closed fracture
S52.319A	Greenstick fracture of shaft of radius, unspecified arm, initial encounter for closed fracture
Transverse Fracture
S52.321A	Displaced transverse fracture of shaft of right radius, initial encounter for closed fracture
S52.322A	Displaced transverse fracture of shaft of left radius, initial encounter for closed fracture
S52.323A	Displaced transverse fracture of shaft of unspecified radius, initial encounter for closed fracture
S52.324A	Nondisplaced transverse fracture of shaft of right radius, initial encounter for closed fracture
S52.325A	Nondisplaced transverse fracture of shaft of left radius, initial encounter for closed fracture
S52.326A	Nondisplaced transverse fracture of shaft of unspecified radius, initial encounter for closed fracture
Oblique Fracture
S52.331A	Displaced oblique fracture of shaft of right radius, initial encounter for closed fracture
S52.332A	Displaced oblique fracture of shaft of left radius, initial encounter for closed fracture
S52.333A	Displaced oblique fracture of shaft of unspecified radius, initial encounter for closed fracture
S52.334A	Nondisplaced oblique fracture of shaft of right radius, initial encounter for closed fracture
S52.335A	Nondisplaced oblique fracture of shaft of left radius, initial encounter for closed fracture
S52.336A	Nondisplaced oblique fracture of shaft of unspecified radius, initial encounter for closed fracture
Spiral Fracture
S52.341A	Displaced spiral fracture of shaft of radius, right arm, initial encounter for closed fracture
S52.342A	Displaced spiral fracture of shaft of radius, left arm, initial encounter for closed fracture
S52.343A	Displaced spiral fracture of shaft of radius, unspecified arm, initial encounter for closed fracture
S52.344A	Nondisplaced spiral fracture of shaft of radius, right arm, initial encounter for closed fracture
S52.345A	Nondisplaced spiral fracture of shaft of radius, left arm, initial encounter for closed fracture
S52.346A	Nondisplaced spiral fracture of shaft of radius, unspecified arm, initial encounter for closed fracture
Comminuted Fracture
S52.351A	Displaced comminuted fracture of shaft of radius, right arm, initial encounter for closed fracture
S52.352A	Displaced comminuted fracture of shaft of radius, left arm, initial encounter for closed fracture
S52.353A	Displaced comminuted fracture of shaft of radius, unspecified arm, initial encounter for closed fracture
S52.354A	Nondisplaced comminuted fracture of shaft of radius, right arm, initial encounter for closed fracture
S52.355A	Nondisplaced comminuted fracture of shaft of radius, left arm, initial encounter for closed fracture
S52.356A	Nondisplaced comminuted fracture of shaft of radius, unspecified arm, initial encounter for closed fracture
Segmental Fracture
S52.361A	Displaced segmental fracture of shaft of radius, right arm, initial encounter for closed fracture
S52.362A	Displaced segmental fracture of shaft of radius, left arm, initial encounter for closed fracture
S52.363A	Displaced segmental fracture of shaft of radius, unspecified arm, initial encounter for closed fracture
S52.364A	Nondisplaced segmental fracture of shaft of radius, right arm, initial encounter for closed fracture
S52.365A	Nondisplaced segmental fracture of shaft of radius, left arm, initial encounter for closed fracture
S52.366A	Nondisplaced segmental fracture of shaft of radius, unspecified arm, initial encounter for closed fracture
Bent Bone
S52.381A	Bent bone of right radius, initial encounter for closed fracture
S52.382A	Bent bone of left radius, initial encounter for closed fracture
S52.389A	Bent bone of unspecified radius, initial encounter for closed fracture
Other Fracture
S52.391A	Other fracture of shaft of radius, right arm, initial encounter for closed fracture
S52.392A	Other fracture of shaft of radius, left arm, initial encounter for closed fracture
S52.399A	Other fracture of shaft of radius, unspecified arm, initial encounter for closed fracture
Galeazzi’s
S52.371A	Galeazzi’s fracture of right radius, initial encounter for closed fracture
S52.372A	Galeazzi’s fracture of left radius, initial encounter for closed fracture
S52.379A	Galeazzi’s fracture of unspecified radius, initial encounter for closed fracture
Ulna Shaft
Unspecified Fracture
S52.201A	Unspecified fracture of shaft of right ulna, initial encounter for closed fracture
S52.202A	Unspecified fracture of shaft of left ulna, initial encounter for closed fracture
S52.209A	Unspecified fracture of shaft of unspecified ulna, initial encounter for closed fracture
Greenstick Fracture
S52.211A	Greenstick fracture of shaft of right ulna, initial encounter for closed fracture
S52.212A	Greenstick fracture of shaft of left ulna, initial encounter for closed fracture
S52.219A	Greenstick fracture of shaft of unspecified ulna, initial encounter for closed fracture
Transverse Fracture
S52.221A	Displaced transverse fracture of shaft of right ulna, initial encounter for closed fracture
S52.222A	Displaced transverse fracture of shaft of left ulna, initial encounter for closed fracture
S52.223A	Displaced transverse fracture of shaft of unspecified ulna, initial encounter for closed fracture
S52.224A	Nondisplaced transverse fracture of shaft of right ulna, initial encounter for closed fracture
S52.225A	Nondisplaced transverse fracture of shaft of left ulna, initial encounter for closed fracture
S52.226A	Nondisplaced transverse fracture of shaft of unspecified ulna, initial encounter for closed fracture
Oblique Fracture
S52.231A	Displaced oblique fracture of shaft of right ulna, initial encounter for closed fracture
S52.232A	Displaced oblique fracture of shaft of left ulna, initial encounter for closed fracture
S52.233A	Displaced oblique fracture of shaft of unspecified ulna, initial encounter for closed fracture
S52.234A	Nondisplaced oblique fracture of shaft of right ulna, initial encounter for closed fracture
S52.235A	Nondisplaced oblique fracture of shaft of left ulna, initial encounter for closed fracture
S52.236A	Nondisplaced oblique fracture of shaft of unspecified ulna, initial encounter for closed fracture
Spiral Fracture
S52.241A	Displaced spiral fracture of shaft of ulna, right arm, initial encounter for closed fracture
S52.242A	Displaced spiral fracture of shaft of ulna, left arm, initial encounter for closed fracture
S52.243A	Displaced spiral fracture of shaft of ulna, unspecified arm, initial encounter for closed fracture
S52.244A	Nondisplaced spiral fracture of shaft of ulna, right arm, initial encounter for closed fracture
S52.245A	Nondisplaced spiral fracture of shaft of ulna, left arm, initial encounter for closed fracture
S52.246A	Nondisplaced spiral fracture of shaft of ulna, unspecified arm, initial encounter for closed fracture
Comminuted Fracture
S52.251A	Displaced comminuted fracture of shaft of ulna, right arm, initial encounter for closed fracture
S52.252A	Displaced comminuted fracture of shaft of ulna, left arm, initial encounter for closed fracture
S52.253A	Displaced comminuted fracture of shaft of ulna, unspecified arm, initial encounter for closed fracture
S52.254A	Nondisplaced comminuted fracture of shaft of ulna, right arm, initial encounter for closed fracture
S52.255A	Nondisplaced comminuted fracture of shaft of ulna, left arm, initial encounter for closed fracture
S52.256A	Nondisplaced comminuted fracture of shaft of ulna, unspecified arm, initial encounter for closed fracture
Segmental Fracture
S52.261A	Displaced segmental fracture of shaft of ulna, right arm, initial encounter for closed fracture
S52.262A	Displaced segmental fracture of shaft of ulna, left arm, initial encounter for closed fracture
S52.263A	Displaced segmental fracture of shaft of ulna, unspecified arm, initial encounter for closed fracture
S52.264A	Nondisplaced segmental fracture of shaft of ulna, right arm, initial encounter for closed fracture
S52.265A	Nondisplaced segmental fracture of shaft of ulna, left arm, initial encounter for closed fracture
S52.266A	Nondisplaced segmental fracture of shaft of ulna, unspecified arm, initial encounter for closed fracture
Bent Bone
S52.281A	Bent bone of right ulna, initial encounter for closed fracture
S52.282A	Bent bone of left ulna, initial encounter for closed fracture
S52.283A	Bent bone of unspecified ulna, initial encounter for closed fracture
Other Fracture
S52.291A	Other fracture of shaft of right ulna, initial encounter for closed fracture
S52.292A	Other fracture of shaft of left ulna, initial encounter for closed fracture
S52.299A	Other fracture of shaft of unspecified ulna, initial encounter for closed fracture
Note: There are no combined codes for fracture of shaft of radius with ulna. Two codes, one from subcategory S52.2- Fracture of shaft of ulna and one from subcategory S52.3- Fracture of shaft of radius, are required to capture fractures of the radius with the ulna.
Monteggia’s
S52.271A	Monteggia’s fracture of right ulna, initial encounter for closed fracture
S52.272A	Monteggia’s fracture of left ulna, initial encounter for closed fracture
S52.279A	Monteggia’s fracture of unspecified ulna, initial encounter for closed fracture

Note 1: The initial encounter for an open fracture is reported with the same codes listed above except that the 7th character extension ‘A’ is replaced with a ‘B’ or ‘C’ as follows:

BInitial encounter for open fracture type I or II or not otherwise specified (NOS)

CInitial encounter for open fracture type IIIA, IIIB, or IIIC

Note 2: Monteggia’s fracture is classified as a fracture of the ulnar shaft (upper region of ulnar shaft).

Note 3: Galeazzi’s fracture is classified as a fracture of the radial shaft (lower region of radial shaft).

Documentation and Coding Example

Ten-year-old Caucasian female brought to ED by parent with bilateral forearm injuries. Child was on a school sponsored picnic to a local public park when she fell from a rope swing, landing on outstretched arms. Accident occurred approximately 15 minutes ago. She is ambulatory, pale and diaphoretic, crying but cooperative with her arms braced against her body. There is obvious deformity of both forearms with patient c/o severe pain in the area of deformity and also some numbness in forearm and hand on the right. Placed on monitors, HR 104, RR 18, BP 76/40, O2 saturation on RA 94%. AP and lateral films of both upper extremities obtained. The most serious fracture appears to be in the right arm with a closed, displaced comminuted fracture of the radius and a nondisplaced oblique fracture of the ulna, both at midshaft level. Left arm has a closed, displaced Galeazzi type fracture of the lower radius with dislocation of the ulna at the wrist. Orthopedics called to evaluate patient. Decision made after discussion with parents to attempt closed reduction with conscious sedation/MAC in ED. Anesthesiologist here, IV started in right foot. O2 started at 2 L/m via NC. Patient comfortably sedated with Versed, Propofol, and Fentanyl. All fractures easily reduced. Soft cast/splints applied. X-rays show satisfactory alignment of all bones. Patient tolerated procedure well, monitored x 1 hour by anesthesia and cleared for discharge home. Appointment made for orthopedic clinic visit in 5 days. Alignment will be evaluated with repeat x-rays, possible hard cast placement if alignment remains satisfactory.

Diagnosis Code(s)

S52.351A	Displaced comminuted fracture of shaft of right radius, initial encounter for closed fracture
S52.234A	Nondisplaced oblique fracture of shaft of right ulna, initial encounter for closed fracture
S52.372A	Galeazzi’s fracture of left radius, initial encounter for closed fracture
W09.1XXA	Fall from playground swing, initial encounter
Y92.830	Pubic park as place of occurrence of the external cause

Coding Note(s)

Galeazzi’s fracture by definition involves fracture of lower shaft of radius with radioulnar joint dislocation so the dislocation is not coded separately.

Fracture of Carpal Bones

Fractures of the carpal bones require documentation of the specific carpal bone fractured. For fractures of the navicular and hamate bones, additional information is required related to the site of the fracture.

Coding and Documentation Requirements

Identify site:

•Capitate (os magnum)

•Hamate (unciform)

–Body

–Hook process

•Lunate

•Navicular (scaphoid)

–Distal pole

–Middle third (waist)

–Proximal third

–Unspecified

•Pisiform

•Trapezoid (smaller multangular)

•Trapezium (larger multangular)

•Triquetrum (cuneiform)

•Other and unspecified carpal bone fracture

Identify fracture status:

•Displaced

•Nondisplaced

Identify laterality:

•Right

•Left

•Unspecified

Identify fracture as:

•Closed

•Open

Identify episode of care:

•Initial encounter

•Subsequent encounter

–With routine healing

–With delayed healing

–With nonunion

–With malunion

•Sequela

Fracture of Carpal Navicula (Scaphoid) Bone

ICD-10-CM Code/Documentation
Unspecified site navicular bone
S62.001-	Unspecified fracture of navicular [scaphoid] bone of right wrist
S62.002-	Unspecified fracture of navicular [scaphoid] bone of left wrist
S62.009-	Unspecified fracture of navicular [scaphoid] bone of unspecified wrist
Distal pole
S62.011-	Displaced fracture of distal pole of navicular [scaphoid] bone of right wrist
S62.012-	Displaced fracture of distal pole of navicular [scaphoid] bone of left wrist
S62.013-	Displaced fracture of distal pole of navicular [scaphoid] bone of unspecified wrist
S62.014-	Nondisplaced fracture of distal pole of navicular [scaphoid] bone of right wrist
S62.015-	Nondisplaced fracture of distal pole of navicular [scaphoid] bone of left wrist
S62.016-	Nondisplaced fracture of distal pole of navicular [scaphoid] bone of unspecified wrist
Middle third
S62.021-	Displaced fracture of middle third of navicular [scaphoid] bone of right wrist
S62.022-	Displaced fracture of middle third of navicular [scaphoid] bone of left wrist
S62.023-	Displaced fracture of middle third of navicular [scaphoid] bone of unspecified wrist
S62.024-	Nondisplaced fracture of middle third of navicular [scaphoid] bone of right wrist
S62.025-	Nondisplaced fracture of middle third of navicular [scaphoid] bone of left wrist
S62.026-	Nondisplaced fracture of middle third of navicular [scaphoid] bone of unspecified wrist
Proximal third
S62.031-	Displaced fracture of proximal third of navicular [scaphoid] bone of right wrist
S62.032-	Displaced fracture of proximal third of navicular [scaphoid] bone of left wrist
S62.033-	Displaced fracture of proximal third of navicular [scaphoid] bone of unspecified wrist
S62.034-	Nondisplaced fracture of proximal third of navicular [scaphoid] bone of right wrist
S62.035-	Nondisplaced fracture of proximal third of navicular [scaphoid] bone of left wrist
S62.036-	Nondisplaced fracture of proximal third of navicular [scaphoid] bone of unspecified wrist

Note: For initial encounter for closed fracture, use 7th character ‘A’; for initial encounter for open fracture, use 7th character ‘B’. The Gustilo classification for open fractures does not apply to carpal bone fractures.

Documentation and Coding Example

Thirty-two-year-old Black male presents to Urgent Care clinic with c/o pain, swelling in left wrist x 2 weeks. Patient injured his hand when he slipped and fell on an icy public sidewalk. Patient did not seek medical care for the injury until today because he has been traveling. On examination, there is swelling at the base of left thumb with marked tenderness when palpated. Patient describes the pain as deep and aching. Grip is weaker on the left. X-ray of left hand and wrist reveals a closed, nondisplaced, vertical fracture through the proximal pole carpal navicular. Telephone consult with orthopedist on-call. Fracture will be treated conservatively with short arm, thumb spica cast. Patient is given the name and contact number for consulting orthopedist with instructions to see him in 2 weeks for re-evaluation. Patient is cautioned that this type of fracture has a high risk of avascular necrosis, especially given the delay with diagnosis and treatment.

Diagnosis Code(s)

S62.035A	Nondisplaced fracture of proximal third of navicular [scaphoid] bone of left wrist, initial encounter for closed fracture
W00.0XXA	Fall on same level due to ice and snow
Y92.480	Sidewalk as place of occurrence of external cause

Coding Note(s)

The place of occurrence in the scenario is a public sidewalk. There is a specific code for sidewalk as the place of occurrence of the external cause.

Fracture of Metacarpal Bones

There are two subcategories for fractures of the metacarpal bones, S62.2 Fracture of first metacarpal bone (thumb), and S62.3 Fracture of other and unspecified metacarpal bone. For fractures of the first metacarpal bone, codes are then classified by general site as the base, shaft, or neck. Fractures of the base of the metacarpal bone of the thumb include specific codes for Bennett’s fractures and Rolando’s fractures as well as a code for other fracture of the base of the first metacarpal. The 6th character captures displaced/nondisplaced status of the fracture and laterality. Fractures of other and unspecified metacarpal bones are specific to general site (base, shaft, neck), the specific metacarpal bone fractured (second, third, fourth, fifth), displaced/nondisplaced status of the fracture, and laterality.

Coding and Documentation Requirements

Identify metacarpal bone fractured:

•First metacarpal (thumb)

•Other metacarpal bone

–Second

–Third

–Fourth

–Fifth

For thumb, identify fracture site/type:

•Base

–Bennett’s fracture

–Rolando’s fracture

–Other fracture of base

•Neck

•Shaft

•Unspecified site/type

For other metacarpal bones (second, third, fourth, fifth), identify fracture site:

•Base

•Neck

•Shaft

•Other fracture

•Unspecified fracture

Identify fracture status:

•Displaced

•Nondisplaced

Identify laterality:

•Right

•Left

•Unspecified

Identify fracture as:

•Closed

•Open

Identify episode of care:

•Initial encounter

•Subsequent encounter

–With routine healing

–With delayed healing

–With nonunion

–With malunion

•Sequela

Fracture Base of First Metacarpal (Thumb)

ICD-10-CM Code/Documentation
Closed Fracture
Unspecified Fracture
S62.201A	Unspecified fracture of first metacarpal bone, right hand, initial encounter for closed fracture
S62.202A	Unspecified fracture of first metacarpal bone, left hand, initial encounter for closed fracture
S62.209A	Unspecified fracture of first metacarpal bone, unspecified hand, initial encounter for closed fracture
Bennett’s Fracture
S62.211A	Bennett’s fracture, right hand, initial encounter for closed fracture
S62.212A	Bennett’s fracture, left hand, initial encounter for closed fracture
S62.213A	Bennett’s fracture, unspecified hand, initial encounter for closed fracture
Rolando’s Fracture
S62.221A	Displaced Rolando’s fracture right hand, initial encounter for closed fracture
S62.222A	Displaced Rolando’s fracture left hand, initial encounter for closed fracture
S62.223A	Displaced Rolando’s fracture unspecified hand, initial encounter for closed fracture
S62.224A	Nondisplaced Rolando’s fracture right hand, initial encounter for closed fracture
S62.225A	Nondisplaced Rolando’s fracture left hand, initial encounter for closed fracture
S62.226A	Nondisplaced Rolando’s fracture unspecified hand, initial encounter for closed fracture
Other Displaced Fracture
S62.231A	Other displaced fracture base of first metacarpal bone, right hand, initial encounter for closed fracture
S62.232A	Other displaced fracture base of first metacarpal bone, left hand, initial encounter for closed fracture
S62.233A	Other displaced fracture base of first metacarpal bone, unspecified hand, initial encounter for closed fracture
S62.234A	Other nondisplaced fracture base of first metacarpal bone, right hand, initial encounter for closed fracture
S62.235A	Other nondisplaced fracture base of first metacarpal bone, left hand, initial encounter for closed fracture
S62.236A	Other nondisplaced fracture base of first metacarpal bone, unspecified hand, initial encounter for closed fracture
Open Fracture
Unspecified Fracture
S62.201B	Unspecified fracture of first metacarpal bone, right hand, initial encounter for open fracture
S62.202B	Unspecified fracture of first metacarpal bone, left hand, initial encounter for open fracture
S62.209B	Unspecified fracture of first metacarpal bone, unspecified hand, initial encounter for open fracture
Bennett’s Fracture
S62.211B	Bennett’s fracture, right hand, initial encounter for open fracture
S62.212B	Bennett’s fracture, left hand, initial encounter for open fracture
S62.213B	Bennett’s fracture, unspecified hand, initial encounter for open fracture
Rolando’s Fracture
S62.221B	Displaced Rolando’s fracture right hand, initial encounter for open fracture
S62.222B	Displaced Rolando’s fracture left hand, initial encounter for open fracture
S62.223B	Displaced Rolando’s fracture unspecified hand, initial encounter for open fracture
S62.224B	Nondisplaced Rolando’s fracture, right hand, initial encounter for open fracture
S62.225B	Nondisplaced Rolando’s fracture, left hand, initial encounter for open fracture
S62.226B	Nondisplaced Rolando’s fracture, unspecified hand, initial encounter for open fracture
Other Displaced Fracture
S62.231B	Other displaced fracture base of first metacarpal bone, right hand, initial encounter for open fracture
S62.232B	Other displaced fracture base of first metacarpal bone, left hand, initial encounter for open fracture
S62.233B	Other displaced fracture base of first metacarpal bone, unspecified hand, initial encounter for open fracture
S62.234B	Other nondisplaced fracture base of first metacarpal bone, right hand, initial encounter for open fracture
S62.235B	Other nondisplaced fracture base of first metacarpal bone, left hand, initial encounter for open fracture
S62.236B	Other nondisplaced fracture base of first metacarpal bone, unspecified hand, initial encounter for open fracture

Documentation and Coding Example

Twenty-two-year-old construction worker arrives in ED with an open wound to his right hand. This well-developed, well-nourished Caucasian male states he was working outdoors on a private home remodeling job when a piece of equipment fell from the roof. He reacted by placing his hand up to shield his head with the tool striking his hand and causing the injury. On examination, there is visual deformity toward the base of the right thumb. An opening in the skin, 3 cm long x 1 cm deep with minimal bleeding and easily approximated skin edges is present. There are no boney fragments visible through the open skin. Wound irrigated with dilute betadine/H2O and gauze dressing applied. Pt taken to x-ray for AP, lateral, and Robert’s view of right hand. Films show a comminuted intraarticular fracture in three fragments including the metacarpal shaft, dorsal metacarpal base, and volar metacarpal base. Care turned over to orthopedic service and patient taken to OR for further exploration, debridement of wound, reduction of displaced fragments, and pin fixation of fracture and antibiotic coverage.

Final diagnosis: Open Rolando’s fracture, right thumb

Diagnosis Code(s)

S62.221B	Displaced Rolando’s fracture, right hand, initial encounter for open fracture
W20.8XXA	Other cause of strike by thrown, projected or falling object, initial encounter
Y93.H3	Activity, building and construction
Y99.0	Civilian activity done for income or pay

Coding Note(s)

Open fractures include any fracture that has direct communication with the external environment. The open wound may be caused by the fracture penetrating the skin or the traumatic event may have resulted in an open wound with an underlying fracture. The presence of an open wound with a fracture does not necessarily mean there is an open fracture. Provider documentation must clearly support the relationship of the wound and the fracture. The description of the fracture fragments as including the metacarpal shaft, dorsal metacarpal base, and volar metacarpal base might lead one to believe that this type of fracture would be coded as S62.291 Other fracture of first metacarpal bone, right hand. However, a Rolando’s fracture is a comminuted intraarticular fracture of the base of the 1^st metacarpal in a Y or T configuration resulting in an extension into the shaft as well as base. There is a specific code for a Rolando’s fracture of the thumb. The status of the fracture as open or closed is captured by the 7th character, which in this case is ‘B’ for initial encounter for open fracture.