Coding Epiphyseal/Physeal Fractures
Physeal/Epiphyseal Fractures are fractures of growing children, which can occur from birth all the way up to the full completion of growth, which in some locations can be in young adulthood (the epiphyses of clavicle in particular). The reason these fractures are so important is that they have the potential for disturbed/abnormal growth in the length of the bone over time, resulting in deformity of the bone itself and/or the adjacent joint. In general, the risk is probably the lowest for Salter-Harris Types I and II, but the risk gets higher with the more complicated and complex Types III and IV. In essence, the more complex and complicated the fracture, the greater the need for an “anatomic" reduction and/or restoration of the fracture, with or without internal fixation, in order to minimize the risk of a growth disturbance. The purpose of this Blog is to help define, clarify, and discuss the terms used; the anatomy of growing bones; and the process of bone growth in order to help Coders understand what is involved in coding these fractures.
The Epiphysis is the end of a long bone, at either or both ends, were growth in length occurs. The Physis is the growth plate where lengthening growth actually occurs. The Metaphysis is that part of the bone adjacent to the physis, where the "growth in length” is “added” to the bone. The next segment is the Diaphysis, which is usually referred to as the shaft of the long bone. Starting at the mid-portion of the shaft and progressing either proximally or distally towards the bone ends are in sequence the Diaphysis, the Metaphysis, the Physis/Epiphyseal plate, and finally the Epiphysis. As growth in length occurs, the Epiphysis is “pushed” away from the Diaphysis. Growth in the width, diameter, and/or size of the bone other than in length occurs as the result of Periosteal growth. The Periosteum is like the “bark of a tree” which adds to the width and circumference of the tree, but does not add to the height of the tree.
Apophyses are also “growth centers” which do have a Physeal plate between the Apophysis and the long bone, but Apophyses do not add length to the bone, but add bony prominences to the side of the bone. Examples would be Greater and Lesser Trochanters of the femur, the Greater and Lesser Tuberosities of the humerus, and the Medial and/or Lateral Epicondyles of the distal humerus. Fractures do occur to Apophyses in growing children, but are not considered Epiphyseal/Physeal fractures. Consequently, the coding for these fractures is not included in the coding for Salter-Harris Epiphyseal fractures, but are normally coded in the Code Sets for long bone fractures. As such, the coding of Apophyseal fractures is not included in this Blog.
The Salter-Harris Classification is used to identify the different types of Epiphyseal fractures. For the sake of brevity, I will use SH as an abbreviation for Salter-Harris in this Blog. The codes for these fractures are not included in the codes for long bone fractures, but are under "Other and Unspecified injuries of the … limb/extremity”
(S 9. _). Code Set S49 includes epiphyseal fractures of the proximal and distal humerus. Code Set S59 includes epiphyseal fractures of the proximal radius only, and the distal radius and ulna. It does not recognize any epiphyseal fractures of the proximal ulna. Code Set S69 does not even recognize the possibility of epiphyseal fractures involving the metacarpals or phalanges, which are fractures that can occur in growing children. Code Set S79 includes epiphyseal fractures of the proximal and distal femur. As it relates to the proximal femoral epiphysis, I refer you to the Blog on Hip Fractures. Code Set S89 includes epiphyseal fractures of the proximal and distal tibia and fibula. The S99 Code Set, as a result of the 2017 Coding Updates, now recognizes and codes for fractures of the Calcaneal Tuberosity (which most of us consider to be an Apophysis) and for epiphyseal fractures involving the metatarsals and phalanges. This Code Set also allows for 7th Character identification of both closed and open (Gustilo Grade I and II types only). Furthermore, the 7th Character B is the only 7th Character allowed for these fractures, and applies only to the Initial Evaluation. The 7th Characters designating abnormal healing (delayed union, nonunion, and malunion) of these open fractures for Subsequent Evaluation are not allowed for use. I am not sure the rationale for this restriction or limitation.
As would be expected from these being S Codes, they do require 7 Characters. With the exception of the fractures of the foot epiphyses/apophyses just discussed, all other Epiphyseal/Physeal fractures are considered closed. As such, the only allowable 7th Characters that can be used for these fractures are A, D, G, K, P, and S. As of the 2017 Coding Updates, and the addition of the S99 Code Set as discussed above, the 7th Character B for open Grade I and II fractures can be used only for the Initial Evaluation, and only for these fractures in the foot. Open Epiphyseal fractures do occur, though are generally rare in the grand scheme of things. The most likely region is in the ankle, less so in the wrist, elbow, and distal femur. These are usually the result of very forceful, violent trauma. The coding for these open epiphyseal fractures presents another ICD-10 coding dilemma. This is the same dilemma that presents itself when trying to code for open joint dislocations, for which ICD-10 does not allow or identify any codes. Based on what information I have, you would have to code an Open Wound with a Foreign Body, with the fractured bone fragments being the "Foreign Body.” To this would have to be added the appropriate SH Fracture code. This would require two codes for the one injury.
I will now discuss the various forms of Epiphyseal fractures of the Salter-Harris (SH) Classification: SH I: This is a fracture which is confined to the physis (epiphyseal plate). It does not turn into or enter either the epiphysis or the metaphysis. These are actually fairly rare by themselves, and usually are non-displaced. The clinical findings are usually local swelling and localized, specific tenderness at the physis and epiphysis. In my experience, the distal fibular epiphysis and the distal radial epiphysis are the most common sites. These can be isolated fractures, but may be a component of a more complex fracture situation. SH II: This fracture goes across the physis, but at some point turns, usually at about 90°, and enters/goes into the metaphysis. These are more likely to be displaced, but this may be mild or minimal. More significant displacement may require a closed reduction for treatment. The most common sites are the distal radius and the distal tibia. SH III: This fracture goes across the physeal plate, then at some point turns (again at about 90°) to enter/goes into the epiphysis. The amount of displacement can vary. In my experience, the most common site for these is in the distal tibia. Because of their higher risk of growth disturbance after healing, these usually require very accurate reduction and fixation in order to minimize this risk. SH IV: This fracture is a combination of SH II and SH III in that the fracture goes through the metaphysis to the physeal plate, partially across that, and then turns into the epiphysis. These are quite complicated fractures, and fortunately are infrequent. Again, the most common site in my experience is in the distal tibia. And again, because of the complexity and higher risk of growth disturbance, accurate reduction and fixation is usually required. “Other" Epiphyseal Fracture is as usual "none of the above.” When I was in training, we recognized the possibility of a SH V fracture, which was an open injury resulting in a “tangential” fracture in one line or plain (i.e. a straight line), through the metaphysis, across the epiphyseal plate, then through the epiphysis. The periosteum and the underlying bone and the cartilage of the epiphyseal plate are essentially “sheared” or “ground” off leaving an exposed area of metaphyseal and epiphyseal bone and the cartilage of the epiphyseal plate in between.
When it comes to the coding for these fractures, the fracture type is designated by the 5th Character which corresponds to the SH Class (I = 1, II = 2, III = 3, & IV = 4) and 9 for “Other". The 6th Character indicates laterality. The 7th Character is as previously discussed. However, the presence or absence of “displacement" is not a factor in the code.
Hopefully, this discussion will educate and help Coders with this complex injury. I would expect/hope that over time, the "Powers that be” will come to the realization that these fractures can be open, and will change the allowable 7th Characters to include all the possibilities that would apply to the Initial and Subsequent Care coding.
Posted in Coding Blogs on Nov 03, 2016