A fracture is a break in a bone. A dislocation is a disturbance or disarrangement of the normal relation of the bones entering into the formation of a joint. A reduction involves repositioning or restoring a bone to its normal anatomical relation by surgical or manipulative procedures. Although these definitions may seem simple, the documentation of fractures, dislocations and their repairs is anything but. Many clinical and technical details are required to accurately code these cases. Here are some of the most common documentation issues for fracture and dislocation treatments.

• External fixation. To assign an additional code for the application of an external fixation system to a fracture site, the documentation must specify the type of fixator as uniplane or multiplane:
• 20690 Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system.
• 20692 Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation system (Ilizarov and Monticelli type, for example).

External fixation is based on the principle of "load transference." Forces normally transmitted through the fracture site are bypassed through the external fixator frame and pin/bone interface at an early stage of treatment. As the fracture callus (formation of new bone around a fracture site) begins to consolidate, more load will be shared by the bone fragments, and eventually the external fixation system is no longer needed and is removed.

Many physicians will list the brand name of the external fixation system (Orthoflix and Ace-Fischer, for example), and no information about whether it was placed in a uniplane or multiplane configuration. This poor documentation results in many coding specialists defaulting to the uniplane code 20690.

• Fracture debridement. To assign an additional code for the debridement of the fracture or dislocation site, the documentation must specify the depth of the debridement through skin, subcutaneous tissue, muscle fascia, muscle and/or bone.
• 11010 Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin and subcutaneous tissues.
• 11011 Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin, subcutaneous tissue, muscle fascia, and muscle.
• 11012 Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin, subcutaneous tissue, muscle fascia, muscle and bone.

Although codes 11010 to 11012 specify "open fracture(s) and/or dislocation(s)," it's also appropriate to report fracture debridement codes if the patient has a closed fracture. Many physicians will document that a fracture site was debrided, but they won't specify the depth of the debridement. When this happens, coders must default to code 11010 for the debridement of skin and subcutaneous tissues.

• Fragment fixation. When you perform an open treatment of distal radius fractures, the documentation must specify if the fracture is extra-articular or intra-articular. If the fracture is intra-articular, the documentation must specify the number of fragments that were fixated. Without this documentation, coders won't know which of these codes to select for the case:
• 25607 Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation.
• 25608 Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 2 fragments.
• 25609 Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 3 or more fragments.

If the fracture extends into the joint, it's intra-articular; if it doesn't, it's extra-articular. For an intra-articular fracture, code options 25608 and 25609 differentiate between the number of fracture fragments that are fixated. The lack of intra-articular and extra-articular documentation results in claims processing delays. There is no default code option — you must query the physician for the missing information before you can completely code and bill this case.

• Fracture location(s). Many of the CPT codes for fracture treatment require documentation of the exact location of the fracture, not just the bone that is fractured (phalanx, metatatarsal or radius, for example), but also the end of the bone that is fractured (distal, shaft or proximal end, for example). The following codes require such details:
• 26727 Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with manipulation, each.
• 26755 Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each.
• 25565 Closed treatment of radial and ulnar shaft fractures; with manipulation.
• 25605 Closed treatment of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation.

While many physicians document the fractured bones, the details about the end(s) of the bone that is fractured are frequently missing. Some physicians will dictate "fracture of both forearm bones" in their operative reports. This statement only provides information about the location of the bones when in fact the forearm bones are the radius and ulna bones. Your coder still needs to know if the shaft and/or distal ends of the radius and ulna bones were fractured. Here, too, there is no default code option available. You'll have to question the physician so you can complete the coding and billing.

• Removal of fracture implants. Effective June 2009, it's only appropriate to report multiple implant removal codes when you removed hardware for another fracture in a different anatomical site unrelated to the first fracture. Implant removal codes 20670 and 20680 describe a unit of service that is reported only once, provided the original injury is located on 1 site, regardless of the number of screws, plates, rods or incisions.
• 20670 Removal of implant; superficial (e.g., buried wire, pin or rod) (separate procedure).
• 20680 Removal of implant; deep (e.g., buried wire, pin, screw, metal band, nail, rod or plate).

Based on these new guidelines, when implants are removed from multiple bones, the physician must document if the implants are being removed from unrelated fracture sites. For example, if deep implants are removed from healing fractures of the radius and ulna, and each bone was treated with separate plates and screws, you'd report code 20680 for the radius implant removal and code 20680-59 for the ulna implant removal.

Many physicians document the removal of implants from multiple bones, but they don't specify if those multiple bones involved separate fractures and separate implants, information which is now critical to accurate coding.

Multiple use of code 20670 and/or 20680 would be appropriate only when you removed the hardware for another fracture in a different anatomical site unrelated to the first fracture (ankle and humerus, for example). In that case, append modifier -59 to subsequent uses of the code. For example, you'd report codes 20680 and 20680-59 or 20670 and 20670-59 if you removed 2 different and non-contiguous implants from 2 different bones or 2 different (non-contiguous) sites on the same bone using multiple incisions.

Universal advice for surgeons
Share these guidelines and issues with your physicians and educate them about the need for timely and comprehensive documentation for all cases.