Coding Counts


August 19, 2016

This month, we’re focusing on coding fractures to the highest specificity by defining the types of fractures and reviewing the use of the 7th alpha character in ICD-10 to identify the episode of care.

Types of Fractures Description
Open Fracture Also known as a compound fracture, this is when the bone breaks through the skin.
Closed Fracture Also known as a simple fracture, this is when the bone breaks, but there is no open wound to the skin.
Complete When the bone breaks into 2 or more parts.
Incomplete When the bone cracks, but does not break all the way through.
Stress When the fracture is a hairline crack
Displaced When the bone breaks into 2 or more parts and moves so that the 2 ends are not lined up straight.
Non-Displaced When the bone either cracks or breaks all the way through, but does not move and maintains its proper alignment.
Pathological When the fracture is caused by a disease that weakens the bones.
Routine Healing When the fracture has healed as expected in an appropriate amount of time.
Delayed Healing When an appropriate amount of time has elapsed, and the fracture has not healed, but there is still a reasonable expectation that the fracture will heal.
Nonunion When a fractured bone fails to heal after an extended recovery period. These can be a result of delayed healing.
Malunion When a fractured bone heals in an abnormal position.

Note: If documentation does not indicate the fracture as displaced or non-displaced, it should be coded as displaced. A fracture not documented as open or closed should be coded as closed.

ICD-10 includes laterality and a 7th alpha character depicting:

7th Alpha Character Description
A – Initial Patient is receiving active treatment for the fracture. Examples of active treatment include:

  • Surgical
  • Emergency room encounter
  • Evaluation
  • Treatment by a new physician
D – Subsequent Encounters for care after the patient has completed active treatment for the fracture and is receiving routine care for the fracture during the healing or recovery phase. This includes:

  • Cast changes or removal
  • Removal of internal or external fixation device
  • Medication adjustments
  • Surveillance while the fracture heals
S – Sequela Reports the after effects, late effects, and other adverse conditions that occur after the healing and recovery phase of the injury.

When reporting sequela, 2 codes are needed:

  • The specific sequela is sequenced first
  • The injury code is sequenced second with the 7th character S

Note: The 7th character “S” is only added to the injury code, not the sequela code.


ICD-10 Code Description
M21.751 Unequal limb length (acquired), right femur
S72.331S Displaced oblique fracture of shaft of right femur, sequela

If you have any questions, email


ICD-10-CM Optum 2015 ICD-10-CM expert for physicians
Optum 2015 detailed instruction for appropriate ICD-10-CM coding
American Academy of Orthopedic Surgeons

Osteoporosis – With or Without Pathological Fracture

June 27, 2016

Age-Related Osteoporosis with Current Pathological Fracture

Report category M80.0 codes when a patient with age-related osteoporosis has a “fragility” fracture from a minor fall or trauma.

ICD-10 combination codes classify:

  • Type of osteoporosis
  • Site of pathological fracture
  • Laterality
  • Encounter episode
ICD-10 Code Description
M80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter
M80.051A Age-related osteoporosis with current pathological fracture, right femur, initial encounter

When coding pathological fractures, use the seventh character A (initial episode) through the entire course of treatment for the fracture.

Age-Related Osteoporosis without Current Pathological Fracture

Report category M81.0 codes when a patient has age-related osteoporosis without a current pathological fracture.

Note: If the patient has a history of a pathological fracture that has healed, first code the osteoporosis and then the history of pathological fracture due to osteoporosis.

ICD-10 Code Description
M81.0 Age-related osteoporosis without current pathological fracture
Z87.310 Personal history of (healed) osteoporosis fracture


If you have any questions, email

You’re Invited! Carle HIM & Health Alliance Provider Workshop

April 19, 2016

You’re Invited!

Carle HIM & Health Alliance Provider Workshop: Audits
Thursday, April 28, 6–8 p.m.

Health Alliance Risk Adjustment Revenue Management and Carle Health Information Management invite you to join us for an evening of discussion on the different types of audits facing our health systems.

Topics include:

  • Carle RAC administrator role
  • Data validation audits:
    • The hospital
    • The health plan

When: Thursday, April 28, 6–8 p.m. Doors open at 5:30 p.m. for refreshments and light snacks.

Where: The Forum at Carle Foundation Hospital

RSVP: Seats are limited. Please RSVP to by Friday, April 22.


Approved for 2.0 AMA PRA Category 1 CreditsTM

The seminar is open to all healthcare professionals who provide care, document services, code and/or bill in any of our participating provider groups and offices.

By the end of the seminar, you will be able to:

  • Describe the different types of audits presented
  • Understand the role that the Carle RAC Administrator plays within the organization
  • Understand the impact of government audits on payment at the national and Carle levels

Carle Foundation Hospital is accredited by the Illinois State Medical Society to provide continuing medical education for physicians.

Carle Foundation Hospital designates this live activity for a maximum of 2.0 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.



Risk Adjustment Documentation

April 13, 2016

This month we are focusing on risk adjustment documentation.

Risk adjustment diagnosis codes are reported based on the medical conditions discussed during face-to-face encounters or hospital stays, when applicable, and should be addressed at least once a year. The Centers for Medicare & Medicaid Services (CMS) conducts risk adjustment data validation (RADV) to ensure documentation supports code submissions on claims to Health Alliance. Use these documentation tips to help support submitted codes.

Code current, ongoing, active and chronic conditions when documentation supports that:

  • Condition is stable, unstable, or worsening
  • Member is to continue current treatment plan
  • Treatment plan is adjusted
  • Member will be referred to a specialist

Example: Chronic atrial fibrillation, stable, no current episodes. Continue Xarelto 20mg and Metoprolol 50 mg daily.

Do not code unconfirmed conditions that are suspected, probable, or ruled out.

Example: I suspect rheumatoid arthritis. Labs ordered to check rheumatoid factor, refer to Rheumatology; follow up in one month.

Link etiology/manifestations and underlying conditions by specifying cause and effect relationship.

Example: Type 2 diabetes with associated CKD stage 3, stable, no change in meds.

  • Code even those conditions being treated by another professional if you had to consider it as a component of your medical decision making.

Example: Patient with significant history of CHF, Type 2 DM & HTN here for swelling of the left foot. Assessment and Plan: Cellulitis of the left foot, start IV antibiotics immediately following in infusion room. CHF, Type 2 DM and HTN all stable on current meds with no changes. Follow up as needed.

International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM)


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HCC 8 through 10 – Cancer Active vs. History of

February 22, 2016

This month we are focusing on correctly coding active cancer vs. a personal history of cancer.

Active Cancer

Active cancer codes support that a malignancy is present or has been excised but treatment is ongoing, (e.g., additional surgery or treatment). Document will state patient has:

  • Active cancer and is receiving ongoing treatment
  • No evidence of active cancer but is receiving adjuvant therapy
  • Active cancer but elects to not receive treatment or no treatment is suggested or recommended
  • Lymphoma documented as “in remission” or “indolent”

History of Cancer

A personal history of malignancy code supports a past diagnosis, by a qualified health professional of cancer, that no longer exists, AND the patient is not receiving active treatment, but has the potential for recurrence, and therefore may require continued monitoring and surveillance.

Documentation Examples

Active Cancer

Diagnostic mammogram along with an ultrasound exam confirmed a 1.7 x 1.2 x 1.3 cm mass within the middle third of the lower-inner right breast. Left breast was normal. An ultrasound-guided core biopsy was carried out and this was confirmed invasive ductal cancer, grade 2/3 with ductal carcinoma in situ (DCIS).

ICD-10-CM Description
D05.11 Intraductal carcinoma in situ of right breast

History of Cancer

76-year-old female diagnosed with breast cancer 5 years ago. Patient is without evidence of recurrent disease and is not receiving active therapy.

ICD-10-CM Description
Z85.3 Personal history of malignant neoplasm, breast


If you have any questions, email