Coding Hip Fractures
Coding Hip Fractures
As common as hip fractures are in adults, and rare in children, and in creating my book from the ICD-10 Coding Manuals, you would think that coding these would be a fairly simple and straightforward process. However, in reviewing Fractures of the Femur (S72) the way these are organized and presented in ICD-10, this is far more confusing and complicated than it should be. I am creating this Blog in an attempt to clarify this. The Authors/Creators of the American version of ICD-10 real made a mess of it. Rather than using the vernacular or common terminology of American Orthopedic Surgeons, they seem to have used very old, outdated terminology, or that derived from “Other World” versions of ICD-10.
First I need to try to clarify some anatomy and terminology as it applies to hip fractures. When I refer to a Hip Fracture, I am referring to any fracture that occurs involving the femoral head, femoral neck, trochanteric region including the greater and lesser trochanters, and the sub-trochanteric region of the upper femoral shaft. One of the terms that is used in ICD-10 is Intracapsular, which as presented is misleading and not specific. The hip capsule extends from the margin of the acetabulum to the base of the femoral neck where it joins the trochanteric region. Therefore, any fracture occurring within the contents of the capsule would be an Intracapsular fracture, in the strictest sense. This would include fractures involving the femoral head and the upper, mid, and base portions of the femoral neck. However, based on the code S72.01 in ICD- 10, this would imply that the only Intracapsular fracture is one involving the femoral neck in the subcapital region, which is the area just below the femoral head. Because it is so misleading, I would not recommend using the term Intracapsular as a diagnosis. For practical purposes, I seriously doubt that any American Orthopedic Surgeons would use the term “Intracapsular Fracture” as a diagnostic term for a femoral neck fracture. Another possible source of confusion is the use of the term Capital as it applies to the proximal femur. “Caput” is the Latin word for “head.” As applied to the femur, it refers to the femoral head. This is how the terms Capital Femoral Epiphysis and Slipped Capital Femoral Epiphysis come to be in our terminology. Also, it is involved in the diagnosis of a Subcapital fracture of the femoral neck, which occurs in the highest part of the femoral neck at its junction with the femoral head.
Also, the coding of hip fractures in ICD-10 mixes both adult and pediatric hip fractures, which I think also adds to the confusion. From my perspective they should be separated. Insofar as they are integrated in ICD-10, there is no way of altering their respective codes, but I can try to organize the information into something easier to understand.
There is a Coding Note which applies to Default Codes, in particular the issue of displaced versus non-displaced/undisplaced fractures. (I use the term non-displaced in preference to the term undisplaced, even though they mean exactly the same thing.) As most Coders are aware, the Default for this is displaced unless it is clearly described as non-displaced. Although the majority of hip fractures are displaced, there are a few that sometimes are not. The issue is what constitutes non-displaced? By a strict definition, a non-displaced fracture is represented by a fracture line of varying degrees of clarity on x-ray, and sometimes requiring a CT or MRI Scan to be certain there is a fracture. In essence, there is no distortion or identifiable deformity in the bony architecture at the site of the fracture. However, physicians may not always adhere to this strict definition, but might say that something that is minimally displaced or distorted is “non-displaced.” Like artwork, “Beauty is in the eye of the beholder.” The fractures of the proximal femur that are often “non-displaced” are fractures of the upper femoral neck (Subcapital). Although these are often mildly “impacted,” which is a mild amount of “displacement.” Also, some fractures of the Greater Trochanter, usually occurring in older adults with osteoporotic bone, may remain non-displaced. Infrequently, an Intertrochanteric fracture will remain in essentially anatomic position, making it a non-displaced fracture.
First I will go through hip fractures as it applies to adults. As previously stated, this includes fractures of the femoral head, femoral neck (upper, mid, and lower or base neck), and the trochanteric (Pertrochanteric in ICD-10) segment of the upper femur, which would include the greater and lesser trochanters and the intertrochanteric region, and finally the subtrochanteric region, which is the very upper end of the femoral shaft.
Starting at the very top would be fractures of the Femoral Head: S72.06 (with 6th Characters of 1 for displaced right, 2 for displaced left, 4 for non-displaced right, and 5 for non-displaced left). These are not very common particularly as isolated phenomenon. They are more often seen as a component of a fracture dislocation of the hip in which a portion of the femoral head is sheared off as it dislocates from the acetabulum.
Next down the anatomy are fractures of the Femoral Neck. The one highest in the neck is the Subcapital Fracture (S72.01 ), i.e. just below the femoral head. These are common in the elderly and may result in varying degrees of impaction and without complete displacement of the femoral head from the femoral neck. These are coded S72.01 , with a 6th Character for laterality. Most Orthopedic Surgeons are likely to use the diagnostic term “Impacted Fracture of the Femoral Neck” for these rather than using “Subcapital.” The next area of the femoral neck is the Mid-cervical or Trans-cervical Fracture. This occurs in the mid portion of the femoral neck, and these are usually completely displaced. The code for this is S72.03 , with the 6th Character indicating both laterality and displacement. The 6th Character 1 is for displaced fracture right, 2 is for displaced left, 4 is for non-displaced right, and 5 is for non-displaced left. The diagnostic term for this fracture used by Orthopedic Surgeons would be “Displaced Fracture of the Femoral Neck” not Mid-cervical or Trans-cervical. The lowest fracture of the neck of the femur is called a Base Neck Fracture. In ICD-10, this is also referred to as Cervicotrochanteric Fracture, a term not commonly used by Orthopedic Surgeons. This fracture occurs at the junction of the femoral neck and the trochanteric segment of the femur. Technically it would be considered an Intracapsular fracture, but this is marginal in that I'm sure that most of the time a portion of the fracture extends outside the capsule. These are usually displaced fractures. The code for this is S72.04 , with the same 6th Characters as previously described. Most Orthopedic Surgeons would use the term “Base Neck Fracture”as their diagnosis.
The next segment of the femur is the Trochanteric segment, called Pertrochanteric in ICD-10. In the adult, this includes fractures of the Greater Trochanter, Lesser Trochanter, and the Intertrochanteric portion. Fractures of the Greater Trochanter, S72.11 , do occur in older adults and can be non-displaced or mildly displaced. Fractures of the Lesser Trochanter, S72.12 , are rare as isolated phenomenon in adults. More often than not, a fracture of the Lesser Trochanter is a part of an Intertrochanteric or Subtrochanteric Fracture. In my opinion, if it is a portion of one of these then it would not need to be coded separately. Intertrochanteric Fractures (literally meaning “between the Trochanters”) are one of the most common types of hip fractures seen in Orthopedics. They can be relatively simple and straightforward, or very complex with comminution of the fracture site resulting in separate Greater or Lesser Trochanteric fragments. As with the femoral neck fractures, the 6th Characters are the same: 1 for displaced right, 2 for displaced left, 4 for non-displaced right, and 5 for non-displaced left.
Next down the femur in adults is the Subtrochanteric Fracture, S72.2 X . These are usually complex and comminuted fractures which may extend up into the trochanteric region as well as down into the shaft of the femur. Occasionally, in severe situations, there may be a mixture of an Intertrochanteric and Subtrochanteric Fractures. If this is the case, I would tend to code both fractures to be on the safe side. The Code Set for Subtrochanteric Fractures is different in that the 5th Character designates laterality and displacement, such that 1 is for displaced right, 2 is for displaced left, 4 is for non-displaced right, and 5 is for non-displaced left. A space holder X is in the 6th Character position.
This covers hip fractures for adults. It might be noted that these codes Excludes(2) periprosthetic fracture of a hip prosthesis (M97.0 X ; 5th Character 1 = R, 2 = L).
I will next try to make some sense out of hip fractures in growing children, those occurring prior to achieving skeletal maturity, which can vary in different portions of the skeleton and at different ages. The Epiphyseal Plate of the upper/proximal femur is more or less contained within the femoral head, with what we would call the metaphysis being the most upper portion of the femoral neck. When the Epiphyseal Plate closes, that completes the formation of the femoral head anatomically. There are two other Growth Centers in the upper femur, which are termed Apophyses. One is for the Greater Trochanter, and the other is for the Lesser Trochanter. For practical purposes, these do not contribute to the length of the femur during growth. Some of the growth in femoral length occurs at the proximal femoral epiphysis, but most of it occurs at the distal femur epiphysis. The Apophyses do have an epiphyseal plate which joins them to the femur. As long as any of these epiphyseal plates are still open, fractures can occur through them resulting in the Epiphyseal or Apophyseal Fractures included in ICD-10.
In the growing child a truly “traumatic” fracture of the Epiphyseal Plate of the femoral head is exceedingly rare. Fractures of the femoral neck in growing children are also rare, but do occur as a result of high energy trauma, such as a car accident. If a femoral neck fracture were to occur in a growing child it would need to be coded the same as for adult femoral neck fractures, since it would not involve the epiphysis. Fractures of the Apophyses, i.e. the Greater and Lesser Trochanters, are also quite infrequent in children, but can occur. The code for a “Traumatic” Epiphyseal Fracture or Separation of the Femoral Neck based on ICD-10 is S72.02 . However, this Excludes(1) S79.01, which is for a Salter-Harris type I Capital Femoral Epiphyses Fracture of the femur. From my perspective, this particular fracture, S72.02, would be so rare that I would not use this code at all. The code for an Apophyseal Fracture of the Trochanters, both Greater and Lesser, is S72.13 , with 6th Character 1 for displaced right, 2 for displaced left, 4 for non-displaced right, and 5 for non-displaced left. The same code applies to each/both trochanteric apophysis. Growing children are capable of having Intertrochanteric and Subtrochanteric fractures as a result of significant trauma, and would be coded the same as for adults.
As it relates to a Epiphyseal Fractures of the upper end of the femur, the S79: Other Injuries of the Hip and Thigh Code Set would be best to use. In particular, S79.01 , which is for the Salter-Harris Type I Epiphyseal Fracture of the Upper Femur. Interestingly, this code is also used for "Traumatic" Acute on Chronic Slipped Capital (Upper in ICD-10) Femoral Epiphysis and "Traumatic" Acute Slipped Capital (Upper) Femoral Epiphysis. However, it Excludes the Apophyseal Fractures of the upper femur and “Non-traumatic" Slipped Capital Femoral Epiphysis (M93.02 ). As regards the S79.01 , the 6th Character is only for laterality (1 for right, 2 for left). These are usually displaced so there is no need to code displaced versus non-displaced. These are also declared to be closed fractures with 7th Character choices being limited to A, D, G, K, P, or S.
I need to try to discuss Slipped Capital (Upper) Femoral Epiphysis (SCFE) as it is pertinent to proximal femoral fractures in growing children. This disorder is covered in the Code Set M93: Other Osteochondropathies. In particular, Code Set M93.0 is for “Non-traumatic” Slipped Upper/Capital Femoral Epiphysis. This disorder usually occurs in preadolescent or adolescent children, is more common in males, most of whom are overweight, and more often than not, are not very athletic or physically active. The underlying problem is an abnormal situation with the proximal femoral epiphyseal plate that allows the femoral epiphysis to slide off the metaphysis. This can occur quite suddenly resulting in an Acute Slipped Capital Femoral Epiphysis (M93.01 ), or it can occur slowly resulting in Chronic Slipped Capital Femoral Epiphysis (M 93.02 ). To add to the confusion, there is Acute on Chronic Slipped Capital Femoral Epiphysis (M93.03 ), in which a patient already developing the chronic form has an acute or sudden displacement of the femoral epiphysis superimposed on it. In theory this is a “non-traumatic” event. At issue is what differentiates “traumatic" from “non-traumatic?” For it to be “non-traumatic,” both the isolated Acute and the Acute on Chronic would have to occur under the stresses of normal daily activities, i.e. “spontaneously.” A great deal of the differentiation would have to be based on the history given by the patient as to what they were doing at the time the sudden event occurred. If the stresses applied were anything greater than those of normal daily activity, then it would have to be considered a “Traumatic" Acute Epiphyseal Fracture, i.e. S79.01 _: Salter-Harris type I Epiphyseal Fracture of the Upper End of the Femur, as discussed above. The Code Set M93 does require a 6th Character: 1 for right, 2 for left.
Finally, as it relates to hip fractures of the hip/proximal femur not involving an epiphysis or apophysis, a 7th Character is required. Open fractures of the hip are very rare. They might occur as a result of rather violent trauma, but are probably more likely to result from a penetrating injury such as a gunshot wound.
This is a long discourse on what would appear to be a fairly straightforward topic, but as presented in the ICD-10 coding manuals, and as was said in the introduction, it is very difficult to make sense of it as it is presented there. Hopefully this discussion will help Coders to sort through this and make it more understandable and rational.
Posted in Coding Blogs on Oct 03, 2016