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CurrentCurativePolicy CHP-IP-2026-065

Acute Inpatient Management of Open Fractures

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Governs acute inpatient admission, level of care, continued stay, and discharge readiness for Curative commercial PPO and EPO members of all ages with open fractures of the extremities and pelvis caused by blunt or penetrating trauma.

Policy Summary

PayerCurative

PolicyAcute Inpatient Management of Open Fractures

Policy CodePolicy CHP-IP-2026-065

Change TypeNo material change

Effective DateNot specified

Next Review DateNot specified

Key ActionDocument the mechanism and time of injury, first antibiotic dose, and tetanus status.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All agesApplicable population

24 hoursContinued-stay review

Within 1 hourInitial IV antibiotics

Within 7 daysSoft-tissue coverage

Within 24 hoursIrrigation and debridement

24 hoursPostoperative antibiotics

Acute Inpatient Coverage Criteria

Acute inpatient admission

Acute inpatient admission is medically necessary when ALL of the following are met.

Inpatient admission

Procedure indications
- Indication: Open fracture of a long bone, pelvis, or major joint of any Gustilo type.
- Indication: Gustilo type II or III open fracture at any site.
- Indication: Gross contamination, including soil, farm, water, or sewage exposure, or impaired vascularity.

Policy Summary

PayerCurative

PolicyAcute Inpatient Management of Open Fractures

Policy CodePolicy CHP-IP-2026-065

Change TypeNo material change

Effective DateNot specified

Next Review DateNot specified

Key ActionDocument the mechanism and time of injury, first antibiotic dose, and tetanus status.

SourceLink

On This Page

Indication: Arterial injury, type IIIC injury, absent distal pulses, or ankle-brachial or arterial pressure index below 0.9.below 0.9

Indication: Associated compartment syndrome, neurologic injury, or polytrauma.

Inpatient setting required

Inpatient requirement: Operative irrigation and debridement within 24 hours with planned repeat debridement or staged fixation.within 24 hours
Inpatient requirement: Scheduled IV antibiotics until and after surgical management.
Inpatient requirement: External fixation for damage control or definitive internal fixation.
Inpatient requirement: Vascular repair, flap coverage, or negative-pressure wound therapy requiring inpatient monitoring.
Inpatient requirement: ASA III or higher, poorly controlled diabetes, immunosuppression, or polytrauma requiring postoperative monitoring.ASA III or higher

Observation or outpatient instead of inpatient

Emergency department, outpatient surgery, or observation care is appropriate when ANY of the following applies and no admission criterion is met.

Observation or outpatient care

Outpatient criterion: Gustilo type I open fracture of a distal phalanx or other small bone of the hand or foot that can be irrigated, debrided, and closed in the emergency department or outpatient surgery, with a first dose of IV antibiotics and tetanus prophylaxis.
Outpatient criterion: Type I or II hand or foot open fracture after outpatient debridement and fixation, with expected discharge within 24 hours and oral pain control.within 24 hours

Intensive care unit

ICU care is appropriate when ANY of the following is present.

ICU level of care

ICU criterion: Hemorrhagic shock, massive transfusion, or vasopressor requirement.
ICU criterion: Polytrauma with traumatic brain injury, chest injury, or respiratory failure requiring mechanical ventilation.
ICU criterion: Fat embolism syndrome, rhabdomyolysis with hyperkalemia, or sepsis with organ dysfunction.

Step-down or intermediate care

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

Intermediate care

Intermediate-care criterion: Neurovascular checks every 1 to 2 hours after vascular repair or for compartment-syndrome surveillance.every 1 to 2 hours
Intermediate-care criterion: Hemodynamically stable polytrauma requiring frequent monitoring after damage-control surgery.

Medical-surgical unit

A medical-surgical orthopaedic unit is appropriate when ANY of the following is present.

Medical-surgical criterion: Stable after debridement and fixation while awaiting repeat debridement, definitive fixation, or soft-tissue coverage.
Medical-surgical criterion: Perioperative IV antibiotics, therapy, and wound care in a stable member.

Discharge readiness

Discharge is appropriate when ALL of the following are met.

Discharge criterion: Final debridement is complete with a clean wound; the wound is closed, grafted, or has a viable flap, or negative-pressure wound therapy can be managed as an outpatient.
Discharge criterion: Definitive fixation is complete, or external fixation is stable with a scheduled conversion plan.
Discharge criterion: Prophylactic antibiotics are completed per guideline duration, with no signs of infection and afebrile status for 24 hours.24 hours
Discharge criterion: Neurovascular examination is stable and pain is controlled with oral analgesics.
Discharge criterion: Mobility and weight-bearing plan is established with therapy, VTE prophylaxis plan is documented, and follow-up is arranged within 1 to 2 weeks.follow-up within 1 to 2 weeks

Continued-stay criteria

Continued stay is reviewed every 24 hours and is medically necessary when ANY of the following is documented.

Continued stay

Continued-stay criterion: Planned repeat debridement, staged definitive fixation, or soft-tissue coverage within 7 days of injury.within 7 days
Continued-stay criterion: Postoperative monitoring after vascular repair or flap coverage.
Continued-stay criterion: Established infection requiring IV antibiotics or further surgery.
Continued-stay criterion: Compartment-syndrome surveillance or polytrauma requiring hospital-level care.
Continued-stay criterion: Pain is not controlled with oral analgesics and prevents mobilization.

Minor distal phalanx fractures and other small hand injuries that can be routinely managed in the emergency department or outpatient setting are addressed under observation and outpatient criteria rather than acute inpatient criteria.

Continued prophylactic IV antibiotics without a subsequent operation or documented infection do not meet medical-necessity criteria when given beyond 24 hours after a procedure or beyond 72 hours for highly contaminated wounds.

Inpatient admission does not meet criteria for a type I open distal phalanx fracture managed with emergency-department irrigation and closure because the injury is considered outpatient-appropriate.

A continued acute stay after discharge-readiness criteria are met, solely while awaiting rehabilitation, skilled nursing, or equipment, does not meet an acute inpatient need. Such cases are routed to physician review and discharge planning; authorized days are not retroactively denied solely because of placement delays.

Applicable Coding and Clinical Thresholds

ICD-10-CM open fractures, initial encounterICD-10

S42.001B	Open fracture, initial encounter, type I or II
S42.002B	Open fracture, initial encounter, type I or II
S42.009B	Open fracture, initial encounter, type I or II
S42.011B	Open fracture, initial encounter, type I or II
S42.012B	Open fracture, initial encounter, type I or II
S42.013B	Open fracture, initial encounter, type I or II
S42.014B	Open fracture, initial encounter, type I or II
S42.015B	Open fracture, initial encounter, type I or II
S42.016B	Open fracture, initial encounter, type I or II
S42.017B	Open fracture, initial encounter, type I or II

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Applicable ICD-10-CM CodesICD-10

S42	The source enumerates individual applicable codes beginning with S42 and ending primarily in B.
S52	The source enumerates individual applicable codes beginning with S52 and ending in B or C.
S62	The source enumerates individual applicable codes beginning with S62 and ending primarily in B.
S72	The source enumerates individual applicable codes beginning with S72 and ending in B or C.
S82	The source enumerates individual applicable codes beginning with S82 and ending in B or C.
S92	The source enumerates individual applicable codes beginning with S92 and ending primarily in B.
S32	The source begins enumerating applicable codes beginning with S32 and ending in B.

Applicable ICD-10-CM Diagnosis CodesICD-10Covered

S92.126B
S92.131B
S92.132B
S92.133B
S92.134B
S92.135B
S92.136B
S92.141B
S92.142B
S92.143B

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MS-DRG (FY2027 v44)MS-DRG

480
481
482
492
493
494
495
496
497
503

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1/2

Revenue codesRevenue

0120
0200
0250
0270
0278
0300
0360
0390
0710

Vascular assessment threshold

MeasureAnkle-brachial or arterial pressure index

ThresholdBelow 0.9

Admission relevanceAn index below 0.9 is an inpatient procedure-indication criterion for an open fracture.

Initial IV antibiotic timing

TreatmentInitial IV antibiotics

TimingWithin 1 hour of presentation

EscalationIf antibiotics are not started within 1 hour, administer them immediately and escalate as a quality concern.

Soft-tissue coverage timing

TreatmentSoft-tissue coverage

Target timingWithin 7 days of injury

Discharge relationshipDischarge requires a closed or grafted wound, a viable flap, or outpatient-manageable negative-pressure wound therapy.

Discharge temperature requirement

RequirementAfebrile status before discharge

Minimum period24 hours

Additional discharge conditionThere must be no signs of infection and prophylactic antibiotics must be completed according to guideline duration.

Antibiotic administration timing

TreatmentInitial antibiotic administration

TimingWithin 1 hour of presentation

If delayedAdminister immediately and escalate as a quality concern.

Postoperative antibiotic prophylaxis

Standard durationNo longer than 24 hours after a surgical procedure

Severe contaminationMay continue for as long as 72 hours after a surgical procedure

ExceptionContinuation beyond these limits requires another operation during that period.

Irrigation and debridement timing

ProcedureIrrigation and debridement

Recommended timingWithin 24 hours of presentation whenever possible

Gross contaminationPerform sooner than 24 hours when there is gross contamination.

Documentation and Review Requirements

Documentation Required

Document Injury and Prophylaxis Timing

Document the injury mechanism and time, the time of the first antibiotic dose, and the patient's tetanus status.

Documentation Required

Document Fracture Classification

Document the Gustilo-Anderson classification, including the provisional emergency-department classification and operative confirmation, along with contamination level and related wound findings.

Documentation Required

Document Neurovascular Status

Document the neurovascular examination and any vascular studies performed.

Documentation Required

Document Operative Management

Include operative documentation showing the timing of irrigation and debridement, fixation method, and wound management.

Documentation Required

Document Antibiotic Regimen

Document the antibiotic regimen, including antibiotic selection and start and stop times.

Documentation Required

Document Coverage and Follow-Up

Document the soft-tissue coverage plan and timing, together with the follow-up plan.

Documentation Required

Support the Requested Scope

Ensure the documentation supports the requested quantity, units, and duration. When a service meets criteria but the request exceeds what is supported, approve the supported portion and refer only the unsupported increment for review.

Denial Risk

Prolonged Prophylactic Antibiotics

Refer for physician review when prophylactic IV antibiotics continue beyond 24 hours after a procedure, or beyond 72 hours for a highly contaminated wound, without a subsequent operation or documented infection supporting the continued stay.

Do not issue an automated or non-physician adverse determination.
Apply concurrent review to each continued-stay period; previously authorized days are not retroactively denied.

Denial Risk

Outpatient-Appropriate Minor Fracture

Refer for physician review when an inpatient admission is requested for a type I open distal phalanx fracture managed with emergency-department irrigation and closure, because this scenario is outpatient-appropriate.

The request is not automatically denied by a non-physician reviewer.

Denial Risk

Stay Solely Awaiting Placement

Refer for physician review and discharge planning when the patient remains in an acute stay after discharge readiness criteria are met while awaiting rehabilitation, skilled nursing, equipment, or other post-acute placement.

Awaiting placement alone is not an acute need.
Never retroactively deny days that were already authorized.

Note

Adverse Determinations Require Physician Review

Requests that do not meet criteria must be referred for physician review. Only a licensed physician of the same or similar specialty may issue an adverse determination, after offering the requesting provider a peer-to-peer discussion and meeting applicable plan licensure, specialty, and medical-director requirements.

Automated systems and non-physician clinical reviewers may approve a request in full or in part but may never issue an adverse determination.

Billing Rule

Unsupported Quantity or Duration

When the documentation supports only part of the requested quantity, units, or duration, approve the supported portion separately and refer only the unsupported excess for physician review.

The absence of a criterion addressing a service is not itself a basis for an adverse determination; a physician applies generally accepted standards of medical practice.

Clinical Background

An open fracture communicates with the external environment through a skin wound and carries a high risk of bone and soft-tissue infection. The Gustilo-Anderson system classifies open fractures from type I through IIIC according to wound size, contamination, soft-tissue damage, need for flap coverage, and arterial injury. Management generally includes prompt IV antibiotics, tetanus prophylaxis, irrigation and debridement, stabilization, and timely soft-tissue coverage.

Key Definitions and Planning Benchmarks

Gustilo-Anderson classification

ClassificationGustilo-Anderson type

RangeOpen fractures are classified from type I through type IIIC.

BasisClassification is based on wound size, contamination, soft-tissue injury, need for flap coverage, and arterial injury.

Damage control orthopaedics

ApproachDamage control orthopaedics

PurposeTemporary stabilization, such as spanning external fixation, for a physiologically unstable member.

Definitive fixationDeferred until the member's physiology allows definitive fixation.

Expected length of stay

TermExpected length of stay

UseA planning benchmark for an uncomplicated course.

Coverage implicationIt is not a limit on covered days.