Q&A: Querying for the etiology of traumatic injuries
Q: We recently had a patient admitted for femur fracture from falling off some bleachers to ground. The patient has a history of osteoporosis and takes medications for this disease. The physician does not state traumatic fracture or pathological fracture. How would I query in this instance?
A: Traumatic injuries cannot be assumed; the physician documentation must be clear. If the documentation is not clear, then the provider should be queried.
In ICD-10-CM there are numerous combination codes that specify the type of fracture, the specific site of the fracture, and laterality. The expanded seventh character in ICD-10 is used to identify the severity of the fracture, including displacement statue (if not documented, the default will be displaced), whether the fracture is an open fracture (classified using Gustilo Anderson classification), or closed fracture (if not documented, the default will be closed), and the healing status (routine healing versus delayed healing).
Remember AHA Coding Clinic, Third Quarter, 2014, allows imaging reports to provide greater specificity of the anatomical site when the provider has documented the diagnosis of the fracture.
An example of a query would be:
Dear Doctor So-and-So,
Mrs. Smith, a 68-year-old female with a history of osteoporosis was admitted with a fracture of the femur after falling from a set of bleachers to the ground. Coding guidelines require explicit physician documentation regarding the nature of the fracture. Based on the information provided could you please specify the etiology of the fracture as either:
- Traumatic: ________
- Nontraumatic: _______
- Pathological fracture_______
- Stress fracture_______
Thank you,
CDI Specialist
Editor’s Note: Sharme Brodie RN, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps offered by HCPro, visit www.hcprobootcamps.com/courses/10040/overview.