CurrentCurativePolicy CHP-IP-2026-068

Femoral Shaft Fracture

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Governs acute inpatient admission, level of care, continued stay, and discharge readiness for Curative commercial members aged 18 years and older with closed femoral shaft fractures.

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CurrentCurativePolicy CHP-IP-2026-068

Femoral Shaft Fracture

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Governs acute inpatient admission, level of care, continued stay, and discharge readiness for Curative commercial members aged 18 years and older with closed femoral shaft fractures.

Policy Summary

PayerCurative

PolicyFemoral Shaft Fracture

Policy CodePolicy CHP-IP-2026-068

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit acute inpatient requests with fracture confirmation, a qualifying indication, and documentation of why inpatient care is required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Adults 18+Applicable population

Within 24 hoursDefinitive fixation target

2–4 daysExpected uncomplicated stay

Every 24 hoursReview interval

92%+Discharge oxygen threshold

24–72 hoursFat embolism window

Acute Inpatient Coverage Criteria

Observation or outpatient alternative

Observation or outpatient care may be used only in the limited circumstance described:

Non-inpatient management: A rare nondisplaced or stress-type diaphyseal fracture managed nonoperatively with protected weight bearing and oral analgesics may be managed as an outpatient or with brief observation. Atypical femoral fractures in members taking bisphosphonates are evaluated individually for prophylactic fixation.

Observation or outpatient care is generally not appropriate for an acute adult femoral shaft fracture requiring operative fixation.

Intensive care unit

ICU care is appropriate when ANY of the following are present:

ICU level of care: Hemorrhagic shock, massive transfusion, or vasopressor requirement; fat embolism syndrome or ARDS with SpO2 below 92% on high-flow oxygen or mechanical ventilation; or bilateral femoral fractures or polytrauma with severe traumatic brain injury requiring damage control.

Step-down or intermediate care

Step-down or intermediate care is appropriate when ANY of the following are present:

Step-down or intermediate care: Supplemental oxygen above 4 L/min or rising oxygen requirement in the 72 hours after injury; neurovascular checks every 1 to 2 hours after vascular repair or for compartment surveillance; or resuscitated polytrauma after damage control requiring frequent monitoring.

Medical-surgical unit

Medical-surgical care is appropriate when ANY of the following are present:

Medical-surgical level of care: Isolated femoral shaft fracture before or after intramedullary nailing in a hemodynamically stable member; or physical therapy, venous thromboembolism prophylaxis, and multimodal analgesia after fixation.

Discharge readiness

Discharge is appropriate when ALL of the following are met:

Clinical stability: Hemoglobin is stable for 24 hours without transfusion and the member is hemodynamically stable; SpO2 is 92% or more on room air or baseline with no neurologic change; and the neurovascular examination is intact with a clean wound.
Functional and discharge planning: Pain is controlled on oral analgesics; transfers and ambulation are safe with an assistive device according to weight-bearing orders; and a VTE prophylaxis plan and orthopaedic follow-up within 2 weeks are documented.

Continued stay

Continued stay is medically necessary when ANY of the following is documented:

Continued-stay criteria: Awaiting definitive fixation after damage control with resuscitation in progress; respiratory compromise, fat embolism syndrome, or pneumonia; ongoing transfusion requirement or hemodynamic instability; associated injuries such as vascular repair, compartment syndrome, or open wound requiring inpatient care; or inability to transfer safely despite therapy or pain not controlled on oral analgesics.Review every 24 hours

Extended-stay review

Extended stays require review when a listed clinical complexity is present:

Extended-stay trigger: Damage control with staged fixation, polytrauma, fat embolism syndrome, ARDS, vascular injury, compartment syndrome, or wound infection.Review every 24 hours

The expected length of stay for an isolated, uncomplicated fracture is 2–4 days after fixation; this is a planning benchmark and does not limit covered days.

Does not meet medical-necessity criteria

The following scenarios do not meet medical-necessity criteria and require physician review:

Does not meet criteria: Prolonged skeletal traction as definitive treatment in a resuscitated adult who can undergo fixation; or continued acute inpatient stay after discharge-readiness criteria are met while awaiting rehabilitation or skilled nursing placement.

These requests are referred for physician review and are not denied by an automated system or non-physician reviewer.

Prolonged skeletal traction used as definitive treatment does not meet medical-necessity criteria when the adult member has been resuscitated and can undergo fixation. Such cases are referred for physician review; they are not denied by an automated system or a non-physician reviewer.

A continued acute inpatient stay does not meet medical-necessity criteria when discharge-readiness criteria have been met and the only remaining need is to await rehabilitation or skilled nursing placement. The case is routed to physician review and discharge planning, with no retroactive denial of authorized days.

Coding and Clinical Thresholds

ICD-10-CM femoral shaft fracturesICD-10

S72.301A	Femoral shaft fracture, initial encounter for closed fracture
S72.302A	Femoral shaft fracture, initial encounter for closed fracture
S72.309A	Femoral shaft fracture, initial encounter for closed fracture
S72.321A	Femoral shaft fracture, initial encounter for closed fracture
S72.322A	Femoral shaft fracture, initial encounter for closed fracture
S72.323A	Femoral shaft fracture, initial encounter for closed fracture
S72.324A	Femoral shaft fracture, initial encounter for closed fracture
S72.325A	Femoral shaft fracture, initial encounter for closed fracture
S72.326A	Femoral shaft fracture, initial encounter for closed fracture
S72.331A	Femoral shaft fracture, initial encounter for closed fracture

1–10 of 37

1/4

MS-DRGRevenue

480	MS-DRG FY2027 v44
481	MS-DRG FY2027 v44
482	MS-DRG FY2027 v44
956	MS-DRG FY2027 v44
533	MS-DRG FY2027 v44
534	MS-DRG FY2027 v44

Revenue codesRevenue

0120	Revenue code
0200	Revenue code
0250	Revenue code
0270	Revenue code
0278	Revenue code
0300	Revenue code
0320	Revenue code
0360	Revenue code
0390	Revenue code
0420	Revenue code

1–10 of 11

1/2

Hemoglobin threshold

Hemoglobin drop2 g/dL or more

Hemoglobin threshold

Low hemoglobinBelow 10 g/dL

Polytrauma threshold

Polytrauma severityInjury Severity Score above 15

ICU respiratory threshold

Documentation and Submission Requirements

Documentation Required

Submit Inpatient Medical-Necessity Criteria

Submit documentation supporting acute inpatient admission and medical necessity for the femoral shaft fracture, including imaging confirmation and at least one qualifying clinical or treatment factor.

Femoral shaft fracture confirmed on radiographs or CT.
At least one of the following: displaced or unstable diaphyseal fracture requiring operative fixation; associated ipsilateral femoral neck fracture, open wound, vascular injury, or compartment syndrome; hemoglobin drop of 2 g/dL or more, hemoglobin below 10 g/dL, or hemodynamic instability; or polytrauma with Injury Severity Score above 15 or other major injuries.
Document the inpatient requirement, such as definitive fixation generally within 24 hours when physiologically appropriate; damage-control external fixation or skeletal traction pending resuscitation; blood-product resuscitation with serial hemoglobin monitoring; or postoperative neurovascular, compartment, and respiratory monitoring with regional or multimodal analgesia.

Documentation Required

Document Injury Details

Document the injury circumstances and severity to support medical-necessity review.

Clinical Background

Adult femoral shaft fractures commonly result from high-energy trauma and may involve substantial blood loss or associated injuries, including an ipsilateral femoral neck fracture that should be excluded with dedicated hip imaging. Intramedullary nailing is the usual definitive treatment, generally performed within 24 hours when physiologically appropriate. Damage-control orthopaedics may be used when severe traumatic brain injury, inadequate resuscitation, or significant pulmonary dysfunction makes immediate definitive fixation unsafe. Fat embolism syndrome may develop 24–72 hours after injury and can present with hypoxemia, neurologic changes, and petechiae.

Key Definitions and Planning Benchmarks

Damage control orthopaedics

StabilizationTemporary stabilization with external fixation or skeletal traction

Patient statusUsed in a physiologically unstable patient

Definitive fixationDeferred until resuscitation is complete

Fat embolism syndrome

Respiratory findingsRespiratory insufficiency

Other findingsCerebral involvement and petechial rash after a long-bone fracture

Diagnostic criteriaOften defined by Gurd and Wilson criteria

Policy Summary

PayerCurative

PolicyFemoral Shaft Fracture

Policy CodePolicy CHP-IP-2026-068

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit acute inpatient requests with fracture confirmation, a qualifying indication, and documentation of why inpatient care is required.

SourceLink

On This Page

ICU respiratory threshold

SpO2 below 92% on high-flow oxygen, or mechanical ventilation

Step-down oxygen requirement

Step-down oxygen requirementAbove 4 L/min or rising oxygen requirement in the 72 hours after injury

Discharge oxygen threshold

Discharge oxygen saturationSpO2 92% or more on room air or baseline

Orthopaedic follow-up

Orthopaedic follow-upWithin 2 weeks

Mechanism of injury.
Associated injuries.
Injury Severity Score, if calculated.

Documentation Required

Submit Diagnostic Imaging

Submit diagnostic imaging that confirms the fracture and evaluates for an associated femoral neck fracture.

Radiographs, including dedicated hip views, or CT.
Imaging should exclude an associated femoral neck fracture.

Documentation Required

Document Resuscitation Status

Document the patient’s resuscitation status and evidence of blood loss or physiologic instability.

Hemodynamic status.
Lactate or base deficit.
Transfusion record, including blood products administered.

Documentation Required

Document Fixation or Damage-Control Approach

Document the treatment approach and timing, including why damage control was used when definitive fixation was not performed.

Time of fixation.
If damage-control external fixation or skeletal traction was used, document the clinical reason and the patient’s resuscitation status.

Documentation Required

Provide Monitoring Notes

Provide monitoring documentation supporting the need for inpatient care and postoperative management.

Neurovascular monitoring notes.
Compartment monitoring when clinically applicable.
Respiratory monitoring notes.

Documentation Required

Document Recovery and Disposition

Provide recovery and discharge-planning documentation for the acute admission.

Therapy notes.
Venous thromboembolism prophylaxis plan.
Disposition plan.

Denial Risk

Definitive Traction After Resuscitation

Prolonged skeletal traction as definitive treatment in a resuscitated adult who can undergo fixation does not meet medical-necessity criteria. Such requests are referred for physician review.

Early stabilization is supported because it reduces pulmonary complications and length of stay.

Denial Risk

Acute Stay Solely for Placement

A continued acute stay after the patient is ready for discharge, solely while awaiting rehabilitation or skilled nursing placement, does not meet medical-necessity criteria. Route the case to physician review and discharge planning; do not apply a retroactive denial to authorized days.

The continued stay must be supported by an ongoing acute need, not placement delay alone.

Expected length of stay

PurposePlanning benchmark for an uncomplicated course

Coverage limitationNot a limit on covered days