From 3M Health Information Systems
ICD-10 coding challenge: Gymnastic injury
I am sure many of you watched the games in Rio a few weeks ago. If so, you saw some amazing performances as well as some tumbles and falls. One of more the gruesome injuries that the audience saw was when the French gymnast, Samir Ait Said, attempted a vault and landed poorly breaking his left leg. Those present in the gym as well as television viewers heard the leg fracture and saw the grotesque aftermath of a severely displaced limb. News accounts as well as the athlete himself described an open, displaced fracture of the tibia and fibula. Mr. Said reportedly underwent an emergency open reduction and internal fixation of his fractured leg. Assign diagnosis and procedure codes for this scenario.
S82.402B Unspecified fracture of shaft of fibular, initial encounter for open fracture type I or II, initial encounter for open fracture NOS
S82.202B Unspecified fracture of shaft of left tibia, initial encounter for open fracture type I or II, initial encounter for open fracture NOS
Y92.39 Other specified sports and athletic area as the place of occurrence of the external cause
Y93.43 Activity, gymnastics
0QSH04Z Reposition, left tibia, open approach, with internal fixation device
0QSK04Z Reposition, left fibula, open approach, with internal fixation device
Now that the summer games are over, let’s turn our attention back to coding. If you got all of the codes to this month’s challenge correct, give yourself a gold medal!
The codes for the fractures of the tibia and fibular are unspecified because the information we had to code from was from the press and not an actual medical record. The seventh character assignment for each of these fracture codes allowed us to show that this was the initial encounter for an open fracture of a long bone despite not having access to the physician’s Gustilo classification designation for these open fractures.
We were able to capture the specificity of where the injury occurred (sports and athletic area) and the activity of the patient (gymnastics) quite easily. We did not assign an external cause status code because this information was not provided and the ICD-10-CM Official Guidelines for Coding and Reporting instruct us not to assign this code if we don’t know the patient’s status.
The procedure coding – open reduction and internal fixation of both fractures – was very straightforward.
Sue Belley is a project manager with the consulting services business of 3M Health Information Systems.