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Rib Fractures With Flail Chest and ORIF Coding Challenge

fractured ribs
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**This post was reviewed and updated on January 19, 2024. **

The Coding Challenge

Question: A 35-year-old female was brought into the ED with severe chest pain and difficulty breathing after being involved in an automobile accident. The patient was the driver of a car that collided with another vehicle on the interstate highway. She sustained multiple comminuted and displaced rib fractures on the right side with flail chest. The surgeon performed open reduction and internal fixation of the rib fractures. Five ribs on the right side were reduced. Assign for ICD-10-CM and CPT.

A. S22.5XXA, V43.52XA, Y92.411, 21812-RT
B. S22.5XXB, V43.52XA, Y92.411, 21813-RT
C. S22.5XXB, V43.12XD, Y92.413, 21811-50
D. S22.5XXA, V43.12XA, Y92.413, 21812-LT

Answer: 

A. S22.5XXA, V43.52XA, Y92.411, 21812-RT

Locate and Verify

ICD-10-CM Coding

Flail Chest

In the ICD-10-CM Alphabetic Index, look up Flail/chest S22.5. In the Tabular, we can verify our correct code as:

S22.5XXA, Flail chest, initial encounter for closed fracture

This is an initial encounter for a closed fracture, as the patient is being seen in the ED and is receiving active injury treatment. The injury is due to trauma (blunt force caused by the automobile accident) rather than a pathologic disease, such as osteoporosis, and is, therefore, reported with a code from Chapter 19. Codes from category S22.5 require a 7th character to explain the episode of care. 

Pathologic fractures caused by an underlying condition are found in Chapter 13, Diseases of the Musculoskeletal System and Connective Tissue.

ICD-10-CM codes for rib fractures and flail chest with 7th characters. S22.5-

There is no mention of the fracture puncturing the skin, indicating an open fracture. The coding guidelines tell us a fracture not indicated as open or closed should be coded as closed. 

The fracture is documented as displaced. Flail chest involves a segment of the thoracic wall being displaced and moving independently of the rest of the chest wall, so this makes sense. Even if the fracture is not specified as displaced or nondisplaced, the default is to code it as displaced.  

An instructional note at S00-T88 tells us to “use secondary code(s) from Chapter 20, External causes of morbidity, to indicate the cause of injury.”

External Causes

In the External Causes Index, look up Accident (to)/automobile – see Accident, transport, car occupant/driver/collision (with)/car (traffic) V43.52. We can verify the correct code in the Tabular as:

V43.52XA, Car driver injured in collision with other type car in traffic accident, initial encounter

Codes from this subcategory require a 7th character to describe the episode of care.

There is a “Use additional” note to identify:
Airbag injury (W22.1)
Type of street or road (Y92.4-)
Use of cellular telephone and other electronic equipment at the time of the transport accident (Y93.C-)

The car accident took place on an interstate highway. When we refer to Y92.4- (Type of street or road) in the Tabular, we can verify the correct code as:

Y92.411, Interstate highway as the place of occurrence of the external cause

Place of occurrence should be recorded only at the initial encounter for treatment.

As a matter of course, read all the Includes, Excludes, Code First, and Use Additional notes before making your final code selection. 

CPT Coding

Open reduction, internal fixation

The documentation indicates that open treatment was performed and five fractured ribs were reduced.

Look in the CPT Index under Fracture/open treatment/rib 21811-21813. In the Tabular, we can verify our correct code as:

21812,  Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 4-6 ribs

The coding guidelines instruct us to append modifier 50 to the CPT code for a bilateral procedure, making it 21812-50. However, in this case, the procedure was performed on the right side, so we need to append modifier RT to our code, making it 21812-RT.

CPT codes for open reduction, internal fixation: 21811, 21812, 21813. 21811 does not apply to flail chest.

Incorrect Answers

B, C, and D are incorrect. 

B. S22.5XXB, V43.52XA, Y92.411, 21813-RT. ICD-10-CM code S22.5XXB refers to Flail chest, initial encounter for open fracture. CPT code 21813 refers to Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 7 or more ribs.

C. S22.5XXB, V43.12XD, Y92.413, 21811-50. Again, S22.5XXB is incorrect. V43.12XD refers to Car passenger injured in collision with other type car in nontraffic accident, subsequent encounter. Y92.413 refers to State road as the place of occurrence of the external cause. CPT code 21811 refers to Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs. This code should not be reported for ORIF in the case of flail chest, because flail chest is when three or more ribs are broken in at least two places. Also, modifier 50 is incorrect and indicates a bilateral procedure.

D. S22.5XXA, V43.12XA, Y92.413, 21812-LT. ICD-10-CM code V43.12XA refers to Car passenger injured in collision with other type car in nontraffic accident, initial encounter. As mentioned above, Y92.413 is incorrect. CPT 21812 is the correct code, but the modifier (LT) is incorrect.

Additional Information

Below is some additional information to help you better understand what flail chest is, its symptoms and causes, and how it is treated.

What is Flail Chest?

Flail chest is a severe type of blunt traumatic chest injury that may occur when three or more ribs are broken in at least two places. When these ribs break, the thoracic wall can malfunction, causing a segment of the rib cage to move independently of the rest of the chest wall. Individuals can experience this fracture pattern without developing flail chest. Those who do, however, may suffer from long-term breathing problems and significant complications.  

Symptoms and Causes of Flail Chest

Symptoms include shallow breathing, extreme pain, low oxygen levels in the body tissues (hypoxia), and blue lips or fingers.

According to Science Direct, the main cause of flail chest is blunt chest trauma, often seen after automobile accidents and falls. Other causes include vigorous cardiopulmonary resuscitation (CPR), pathological fractures, and congenital rib abnormalities in newborns.

Treatment

rib cage protects the lungs and heart and surrounding tissues.

Immediate attention is critical to diagnosing and treating flail chest. Prompt care reduces the likelihood of damage to the heart, lungs, and surrounding tissues. 

According to the Lynchburg Journal of Medical Science, rib fractures have been historically treated non-surgically with pain management and oxygen therapy. However, patients with multiple displaced rib fractures or flail chest have a quicker recovery and better outcomes with surgical stabilization with rib plating. 

Surgical stabilization using open reduction and internal fixation (ORIF) is recommended conditionally for patients with flail chest to decrease mortality, shorten the duration of mechanical ventilation, hospital and ICU length of stay, and decrease the incidence of pneumonia and need for tracheostomy.   

Open Reduction and Internal Fixation Procedure

According to the Journal of Cardiothoracic Surgery, a surgeon performs open reduction, internal fixation (ORIF) by making an incision in the skin and subcutaneous tissue of the rib fracture sites. The muscle layer is cut to expose the fractured rib. A claw-type titanium place in the appropriate size is secured to the fractured rib. A steel clamp is used to draw the claw feet of the plate inward so it can hold tightly to the rib.

Some patients require thoracic visualization of the chest wall during surgical rib fixation. Advantages of thoracic visualization during ORIF include better identification of rib fracture locations and exploration of the thoracic cavity for retained hemothorax and additional injuries.

Flail Chest and ORIF Coding
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4 Comments

  1. thank you for this website as i am trying to pass the aapc course. your articles are helping me to clarify things not explained, as i did not sign up for the instructor option in aapc.

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