ICD-10 Coding for Orthopedic Surgery

Due to the higher level of specification, coding for orthopedic surgery in keeping with ICD-10-CM/PCS has to be done meticulously with minute attention to detail. For instance, the new coding system requires more specific information regarding a fracture when choosing the fracture codes. There are vital changes in coding the complications of device as well as the surgical procedure.

Fracture Codes

Here, we are considering hip fractures to understand the changes that have occurred in selecting fracture codes under the new coding system. In ICD-9 coding of hip fractures, there are some specifications regarding the site of femoral fracture. But ICD-10-CM goes further to provide information about the laterality. The ICD-9 code for fracture of neck of femur (hip fracture) is 820. It is further classified into several codes according to the specifications pertaining to the site of femoral fracture. Some of them are given below.

• 820.00: Closed fracture of intracapsular section of neck of femur, unspecified
• 820.01: Closed fracture of epiphysis (separation) (upper) of neck of femur
• 820.02: Closed fracture of midcervical section of neck of femur
• 820.03: Closed fracture of base of neck of femur

The following ICD-10 codes specify the laterality (right or left) along with the specifications regarding the site.

• S72.011A: Unspecified intracapsular fracture of right femur, initial encounter for closed fracture
• S72.012A: Unspecified intracapsular fracture of left femur, initial encounter for closed fracture
• S72.019A: Unspecified intracapsular fracture of unspecified femur, initial encounter for closed fracture

The episode of care information is coded using separate codes in the ICD-9 system while ICD-10 coding specifies that information with the seventh character. For example, the following ICD-9 code is used separately after the hip fracture code, say, 820.00 to specify the healing regardless of whether it is routine healing or delayed healing.

V54.13: Aftercare for healing traumatic fracture of hip

This information can be specified with the appropriate hip fracture code in ICD-10 itself.

S72.019D: Unspecified intracapsular fracture of unspecified femur, subsequent encounter for closed fracture with routine healing

S72.019G: Unspecified intracapsular fracture of unspecified femur, subsequent encounter for closed fracture with delayed healing

Since the episode of care information is included within the fracture code, it will improve the data analysis and the reviewer can identify the number of hip fractures that occurred previously, how many of them are in acute phase, how many of them are in the healing phase and whether there are any complications.

There are separate codes for nonunion and malunion of fractures in ICD-9 such as:

733.81: Malunion of fracture

733.82: Nonunion of fracture

However, the fracture codes within ICD-10 system specify this information also.

S72.012K: Unspecified intracapsular fracture of left femur, subsequent encounter for closed fracture with nonunion

S72.012P: Unspecified intracapsular fracture of left femur, subsequent encounter for closed fracture with malunion

In short, the coder should consider the laterality, episode of care, nonunion and malunion of fractures while choosing the appropriate fracture code under ICD-10.

Complications Associated with a Device

The complication type such as loosening, pain, prosthetic fracture, infection, misalignment etc. should be documented clearly in the clinical information. The joint replacement status needs to be considered in both classification systems. However, there is difference in coding the complications in each coding system. Let’s take the example of a complication, mechanical loosening of prosthetic joint and the problem area is the hip joint. There are two codes in the ICD-9 system to represent the complication and joint replacement status.

996.41: Mechanical loosening of prosthetic joint

V43.64: Hip joint replacement

Coders need not assign a separate code for joint replacement status under ICD-10. However, they should consider the laterality, the exact site, and the episode of care to choose the appropriate code for complication.

• T84.030: Mechanical loosening of internal right hip prosthetic joint
• T84.030A: Mechanical loosening of internal right hip prosthetic joint, initial encounter
• T84.030D: Mechanical loosening of internal right hip prosthetic joint, subsequent encounter
• T84.030S: Mechanical loosening of internal right hip prosthetic joint, sequela
• T84.031: Mechanical loosening of internal left hip prosthetic joint
• T84.031A: Mechanical loosening of internal left hip prosthetic joint, initial encounter
• T84.031D: Mechanical loosening of internal left hip prosthetic joint, subsequent encounter
• T84.031S: Mechanical loosening of internal left hip prosthetic joint, sequela

Arthroplasty

For the arthroplasty procedure, there are three root operation choices such as repair, replacement and supplement. It is very important for the coder to understand the goal of the procedure to select the appropriate procedure code. The original replacement of the joint should be coded with the root operation of the replacement. The root operation is repair while the physician is restoring the joint without any device and supplement while the surgeon is reinforcing the joint without removing the joint. In the ICD-9 system, it is easy to code for this procedure as it is required to just consider arthroplasty and review the subentries for the joint. Medical coders may need to know whether the replacement was complete or partial. In the ICD-10 system, coders will require to know about the type of device inserted, whether that device is cemented or uncemented and the specific body part including the laterality, apart from the root operation. Here are knee arthroplasty codes that specify laterality.

Z96.651: Presence of right artificial knee joint

Z96.652: Presence of left artificial knee joint

Clinical documentation should provide proper and accurate information regarding the site of fractures, the surgical procedure and complications associated with the device so that the coders can assign the most appropriate ICD-10 codes. When it comes to implants, orthopedic practices should determine whether physician documentation or a device record is the source of facts regarding the type of implant inserted. As the implementation date is approaching, orthopedic practices should make necessary changes to their clinical documentation and documentation policies to adopt the coding changes and avoid revenue loss. They can provide comprehensive training for their coders in ICD-10 or seek the services of professional coders having thorough knowledge in ICD-10.

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