Give an example of coding for a fracture diagnosis in ICD-10.

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Here’s an example of how to code a fracture diagnosis using ICD-10-CM:

Scenario:

A 35-year-old patient presents with a displaced fracture of the shaft of the right femur due to a fall. This is the initial encounter for active treatment.

Step-by-Step Coding Process:

1. Identify the Main Term:
   Look up “Fracture, femur, shaft” in the Alphabetic Index.

2. Find the Preliminary Code:
   You’ll find S72.351 – Displaced fracture of shaft of right femur.

3. Determine the 7th Character:
   Since it’s the initial encounter, the 7th character is A (active treatment).

4. Check Code Length:
   The code requires 7 characters, but S72.351 has only 6, so we need a placeholder.

5. Add Placeholder (X):
   Use ‘X’ as the 6th character to hold the place.

Final Code:

S72.351A

• S72: Fracture of femur

• .351: Displaced fracture of shaft of right femur

• A: Initial encounter for active treatment

If It Were a Follow-Up Visit:

Use the same base code with 7th character D (e.g., S72.351D for subsequent encounter).

If It Were a Sequela (Late Effect):

Use 7th character S (e.g., S72.351S).

Conclusion:

ICD-10-CM fracture codes require specificity about:

• Location (e.g., shaft of femur)

• Laterality (e.g., right vs. left)

• Type of fracture (e.g., displaced vs. nondisplaced)

• Phase of care (7th character)

Accurate coding ensures proper clinical documentation and billing.

Read More

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