Fractures — ICD-10-CM coding and documentation guidance
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This document provides ICD-10-CM coding, documentation, and clinical guidance for fractures (traumatic and pathologic), including use of the 7th character and encounter sequencing; it applies to Independence Administrators coding and documentation practices and clinicians/providers submitting claims.
No material clinical or coverage changes in this revision.
Fracture coding and documentation criteria
Fracture coding and documentation criteria
Coding and documentation criteria for fractures used for claims submission and clinical documentation:
ALL of the following
- A - Initial encounter (active treatment): Use 'A' for each encounter where the patient is receiving active treatment (examples: surgical procedures, emergency department care, placement of a cast). Assignment is based on active treatment being provided, not simply whether it is the first visit with the provider.
- D - Subsequent encounter (routine healing): Use 'D' for follow-up encounters during the healing or recovery phase when no active treatment is being rendered (example: follow-up X-ray with no adjustments or interventions).
- S - Sequela: Use 'S' for sequelae — complications or residual effects that arise as a direct result of the original injury after the acute phase has passed (example: contracture due to prolonged immobilization).
ICD-10-CM coding rules for fractures
| ICD-10 fracture codes (category-level guidance) | Fracture codes require a 7th character; the 7th character must occupy the 7th position in the code. Use placeholder 'X' to fill empty characters if needed. If documentation does not specify open versus closed, code as closed; if documentation does not specify displaced versus non-displaced, code as displaced. When multiple fractures are present, sequence codes according to severity. |
| A | Initial encounter: use A for each encounter where the patient is receiving active treatment (e.g., surgical procedures, emergency department care, placement of a cast). Assignment is based on active treatment, not whether it is the first visit with the provider. |
| D | Subsequent encounter: use D for follow-up care during the healing or recovery phase when routine healing is occurring and no active treatment is rendered. |
| S | Sequela: use S for complications or residual effects that arise as a direct result of the original injury after the acute phase has passed. |
Assigning the 7th character and billing actions
7th-character assignment and placeholder use
Assign the correct 7th character (A, D, or S) to all fracture ICD-10-CM codes and use the placeholder 'X' to fill empty characters so the 7th character occupies the 7th position. Use A when the patient is receiving active treatment (for example, surgical procedures, emergency department care, or placement of a cast); use D for subsequent encounters when routine healing is occurring and no active treatment is rendered; use S for sequelae (residual effects or complications of the original injury). Note that assignment is based on whether active treatment is being provided, not on whether it is the provider's first visit with the patient.
- Ensure the 7th character occupies the 7th position in the code; insert an 'X' as a placeholder if needed to reach the 7th position.
- Assign 'A' for encounters where active treatment is provided (examples: cast placement, surgery, ED care).
- Assign 'D' for follow-up visits with routine healing and no active treatment.
- Assign 'S' for sequelae—complications or residual effects after the acute phase.
Key definitions
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