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Some of the sneakiest rules in ICD-9-CM coding that get implemented each year do not involve new codes at all. Rather, these sneaky rule changes are simply changes made in the ICD-9-CM Alphabetical Index directing the coder to report some condition in a manner that’s different from how coders had been directed to report it in the past—and it’s not due to the creation of a new code. It’s just a change in the way the ICD-9-CM folks have decided they want a condition coded.
Unfortunately, these coding instructional changes that don’t involve new codes or deleted codes or even revised codes often get overlooked each year by coders. Here are a few of these new or revised coding instructions from the ICD-9-CM Alphabetical Index, effective 10/01/2007:
Abnormal, abnormality, abnormalities
blood sugar 790.29
Congestion, congestive
- Chest 786.9
- Lung 786.9
- Nose 478.19
Feeling of foreign body in throat 784.99
Gas 787.3
Runny nose 784.99
Scratchy throat 784.99
Swelling 782.3
Again, none of these codes themselves are new for this year. These are simply new coding instructions.
Aftercare fracture care coding
It is sometimes difficult to know when an “aftercare” code is to be used for fracture care coding and when an acute fracture code should be used. Because this has been somewhat confusing in the past (and even the official coding rule language has been somewhat confusing), clarifying language has been added to the ICD-9-CM Official Guidelines for Coding and Reporting:
Traumatic fractures are coded using the acute fracture codes (800-829) while the patient is receiving active treatment for the fracture. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.
Fractures are coded using the aftercare codes (subcategories V54.0, V54.1, V54.8, or V54.9) for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase. Examples of fracture aftercare are: cast change or removal, removal of external or internal fixation device, medication adjustment, and follow up visits following fracture treatment.
You can find these guidelines here.
We learn from these examples that “active treatments” of fractures include:
- Surgical treatments like ORIF procedures
- Fracture treatment in the emergency department
- Evaluation and treatment for the fracture after the patient has been referred to another physician for definitive treatment,[for example, to an orthopedic physician
Each of these above encounters would be reported with the acute fracture code. However, here are some examples of “aftercare:”
- Cast changes or removals
- Removals of externals or internal fixation devices
- Adjusting medications
- Routine follow-up visits following fracture treatment
The first quarter 2005 issue of Coding Clinic for ICD-9-CM has a helpful example:
Question: An eight-year-old, who has a cast on her lower leg and foot because of a fracture of her ankle, uses a pen to scratch inside the cast. The pen cap comes off inside the cast and the patient presents to the emergency department (ED) for evaluation. An examination by the ED physician showed no injury to the leg. The patient was instructed to follow-up with the orthopedist for cast replacement in one week to remove the pen cap. How should the ED encounter be coded?
Answer: Assign code V54.19, Aftercare for healing traumatic fracture of other bone, for the emergency department encounter.
It’s important that coders not use the acute fracture code for subsequent encounters. The National Center for Health Statistics (NCHS) does elaborate statistical tracking. The purpose of the acute care code is to report the initial care and then the aftercare codes are used to report routine follow-up visits. When the acute care code is reported multiple times for a patient, the data make it look like the patient sustained a fracture injury multiple times! The NCHS staff will wrack their brains trying to figure out why patients are repeatedly re-fracturing the same body part. Of course, nothing of the sort would actually be happening, but the statistical data would be deceptive.
Remember, more is done with the information on claims data than just pay claims; it is used for important national health statistical research.
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