The report below describes a patient undergoing surgery for a pathological fracture of the right forearm/wrist. The entire procedure has been documented in detail, describing the step-by-step process used by doctors to carry out the surgery. Keep reading for more on how this procedure was performed.
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Documentation and Coding Example: Fifty-nine-year-old female returns to Orthopedic Clinic for a second postoperative visit. She is now five weeks s/o fall at home where she sustained a fracture of the distal right radius. She presented initially to the ED with pain, swelling, and deformity of the right wrist and forearm with tenderness and swelling of the distal radius. Radiographs showed a distal-radial fracture and severe osteoporosis of the radius and ulna. She underwent an ORIF the same day with the application of a soft cast/splint. She had a hard cast applied at her first post-op visit 3 weeks ago. The patient states she is doing well and has no complaints. Bruising and swelling have subsided in her fingers, and she has good ROM and neurovascular checks. She admits to mild pain, usually associated with overuse, that is relieved with acetaminophen. X-ray in plaster shows the fracture to be in good alignment with increased callus size when compared to previous films. She is taking a Calcium supplement, Vitamin D 6000 units, Vitamin C 1000 mg. Daily and a multivitamin/mineral tablet. The patient is advised to continue with her present supplements. RTC in 3 weeks for x-ray out of plaster and application of splint. The patient is due for an annual physical exam with her PCP in 3 months. She is advised to discuss having a DEXA scan to assess bone density since it has been 6 years since her last one and she has now entered menopause. Once they have those results she may need to consider more aggressive therapy for her osteoporosis.
Coding Notes: Even though the fracture was sustained in a fall, ICD 10-CM coding guidelines state, “A code from category M80, not a traumatic fracture code should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma if that fall or trauma would not usually break a normal healthy bone.” An external cause code may be reported additionally to identify the pathological fracture is
due to a fall. An unspecified fall is reported because the documentation does not provide any information on the circumstances surrounding the fall, such as a fall due to tripping or a fall from one level to another. The 7th character D is assigned to identify this encounter as a subsequent visit for aftercare.
M80.0311D; Age-related osteoporosis with current pathological fracture, right forearm,
subsequent encounter for fracture with routine healing.
W19.XXXD: Unspecified fall, subsequent encounter.
CPT: 99024 Pt is within the 90-day global period