EDITOR’S NOTE: This is the third installment in a three-part series about the author’s encounter with a physician and his staff regarding the clinical documentation of a patient who had suffered a hairline fracture of the left ankle. In this final installment, the author describes the granularity of ICD-10.

Granularity of Documentation Under ICD-10-CM

As compared to the current status of MR documentation, improvements will need to be made in the quality, not quantity, of provider notes, in many instances. Similar to the orthopedic audit we have been discussing, certain patient case specifics, if documented, can improve the clinical data quality and at the same time make it easier for coders to interpret and assign correct ICD-9-CM codes (and prepare for assigning ICD-10-CM codes). That’s a lot of pluses for simply improving the details captured in the MR documentation! We will discuss a few of these documentation specifics only as they pertain to the patient case outlined above for Dr. Jones.

Type of fracture

Let’s begin this subsection with this dictum: If the coder is in doubt about the MR documentation specifics, query the provider. Working off of that directive, we will both query the provider and reread the case notes for missed information. Dr. Jones’ patient sustained a non-traumatic fracture of the left ankle, confirmed by X-ray, but written correlation by the provider was not made to the concomitant osteoporosis in the original MR notes.

The orthopedic coder’s first clue in this case is that the fracture was sustained non-traumatically; when there is no reported trauma or if the patient has sustained minor trauma that in another patient with normal, healthy bone would not have resulted in a fracture to the affected site, a pathologic fracture scenario becomes a possibility. In audit case No. 1 for Dr. Jones, there are also the facts that the patient is elderly and has a documented diagnosis of senile osteoporosis. While all of these fit nicely together in the equation for a pathologic fracture, with ICD-9-CM code 733.16, pathologic fracture of the tibia or fibula (Ankle NOS), and 733.01, senile osteoporosis, the physician practice coder still cannot assume that a pathologic fracture due to senile osteoporosis is present unless the provider has documented the cause-and-effect relationship.

At this time, our query has returned with a confirmed correlation of the fracture to the underlying disease process.


Making note of the right or left side and/or bilateral status is obviously commonplace when coding orthopedic procedures (i.e., when assigning CPT codes), but it has rarely been a part of the diagnosis coding process in the orthopedic arena (with the exception of attributing effects of certain diseases or events, such as paralytic syndrome or CVA, to a specific side of the body such as dominant, nondominant or bilateral). Soon, under ICD-10-CM, laterality will be a common characteristic captured by codes, making the necessity for documenting this information apropos to documenting the case within expected limits. In other words, it will be the new norm. We’ll see how this data impacts the ICD-10-CM code for the pathologic fracture we’re analyzing in case No. 1 in a few minutes.

Types of encounters

As previously implied, the practice coder in this audit case unfortunately erred by making several false assumptions. She assumed that, because the fracture was described as “acute,” it automatically equated to the traumatic fracture categories in ICD-9-CM. Also, she did not query the provider for a correlation to the documented osteoporosis, and she assumed that because the patient was being seen in follow-up, including her last recorded visit for the fracture care, all of those visits were to be coded with the acute fracture code. The latter assumption is actually a very common error in orthopedics, because the coding concept of aftercare is not always readily understood – and there don’t seem to be any penalties or follow-up by payers when practices continue to assign the acute fracture codes throughout the course of the patient’s treatment.

In ICD-9-CM, aftercare is to be assigned following the initial encounter for care of the acute fracture. To make that crystal clear, both the official coding guidelines and Coding Clinic instruct to code the initial encounter (for treatment) with the acute fracture code and to assign an aftercare code for subsequent visits. In this case, under ICD-9-CM, the aftercare code would have been V54.26, aftercare for healing pathologic fracture of lower leg (which includes the ankle, NOS). Therefore, the first remedial step is to understand basic coding principles and guidelines. Not surprisingly, under ICD-10-CM the encounter type is actually embedded in the code, and much like laterality, the encounter type is captured by a single ICD-10-CM code.

In a Nutshell

For audit case No. 1 then, the facts lead us to ICD-10-CM code assignment of M80.072x, “age-related osteoporosis with current pathological fracture, left ankle and foot,” with “x” being reserved for the type of encounter. The initial encounter would be coded with the seventh character x = A, initial encounter for fracture, with the subsequent visits described with V-codes under ICD-9-CM for aftercare (in this particular clinical case, presenting no healing difficulties) denoted by 7th character x = D, subsequent encounter for fracture with routine healing.

Note that with these codes, M80.072A or M80.072D, we have captured the following data sets: a) type of fracture (pathologic), b) underlying disease (age-related osteoporosis), c) laterality (left) and d) the two types of encounters contained in the audit performed: initial and subsequent (aftercare). ICD-9-CM captured some but not all of this data by assigning ICD-9-CM codes (initial encounter) 733.16 + 733.10 and (subsequent encounters) V54.26 + 733.01.


The march into ICD-10 can be eye-opening for many practices, and the process of performing a documentation assessment can cause more than just diagnosis coding issues to emerge. As stated, this particular orthopedic documentation assessment resulted in good news wrapped in a few layers of bad news. The bad news: the practice wasn’t quite ready to begin full-on ICD-10-CM training; certain remedial steps needed to be taken first.

The good news: the practice had a new outline of activities to undertake and a clear path to ICD-10-CM training and implementation. A timeline could be built on these remedial steps, and the practice acquired a window into how to stage their journey, especially considering the recently revised implementation date of Oct. 1, 2014.

Lastly, I advised the orthopedic surgeons to look at all of the discussed coding and documentation guidelines and the various federal/state regulations as protections, not as tethering regulations. The term “regulations” has such a negative connotation. But by following these myriad protections, the practice can improve data quality for clinical purposes and improve its coding accuracy to receive optimum but appropriate reimbursement. It also can stay squarely within federal/state compliance parameters, protecting its hard-earned reimbursements from payer recoupments, and potentially freeing the practice from associated fines, penalties, pre-payment screens of claims and future focused medical reviews.

About the Author

Michael G. Calahan, PA, MBA, is vice president of physician and hospital compliance for HealthCare Consulting Solutions (HCS).

Contact the Author

mikiecal@hotmail or questions@hcsglobal.net

To comment on this article please go to editor@icd10monitor.com

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