Code for Bimalleolar Ankle Fracture
Understanding the ICD-10-CM coding guidelines related to fracture coding is critical in this Name That Code coding exercise. If you understand the pertinent coding guidelines, you should be able to assign the correct code(s) for bimalleolar ankle fracture.
After determining the best answer, read below to see the provided answer and rationale.
Question: A patient is seen for increased pain in his right ankle. He has a previous bimalleolar fracture of this ankle after slipping and falling off a curb. After evaluation, he was found to have a nonunion of his right bimalleolar fracture. Assign the diagnosis code(s). Do not include external cause codes.
Before we provide the answer, let’s learn a little about bimalleolar fractures.
A fracture is a broken bone. A bimalleolar ankle fracture is a fracture that occurs in both the lateral and medial malleoli at the distal end of the tibia and fibula bones, according to StatPearls Publishing. The distal end of the tibia and fibula bones are the parts closest to the ankle.
bi- means two; -malleolar pertains to the malleolus, the rounded, bony protuberance on each side of the ankle joint. Malleoli is plural for malleolus.
A fracture can be traumatic or pathologic. It is important to know the difference between the two in order to assign the right codes. In this case, the bimalleolar ankle fracture is a traumatic fracture, because it was caused by an injury (falling off a curb). A pathologic fracture is caused by disease.
When a fracture does not heal after surgical or nonsurgical treatment, it is called a nonunion.
Locate and Verify
In the alphabetic index, look up Fracture, traumatic (abduction) (adduction) (separation)/ankle/bimalleolar (displaced) S82.84-.
In the tabular listing, we can verify the correct code as:
S82.841K, Displaced bimalleolar fracture of right lower leg, subsequent encounter for closed fracture with nonunion
A 7th character is added to all codes from category S82. The 7th character “K” is used to indicate the patient was seen previously for treatment of the fracture and is now returning for subsequent care for the nonunion. The nonunion is a complication of the fracture.
According to the ICD-10-CM Official Guidelines for Coding and Reporting (FY2022), a fracture not indicated as open or closed should be coded to closed. The coding guidelines also state that a fracture not indicated as displaced or nondisplaced should be coded to displaced.
Some fractures may require more detail depending on the site of the fracture. Open fractures are reported using the Gustilo-Grade Classification system (Types I, II, IIA, etc.).
Additionally, aftercare Z codes should not be used for aftercare for traumatic fractures. Instead, aftercare of a traumatic fracture should be assigned the acute fracture code with the appropriate 7th character.
The patient was seen previously for treatment of the fracture and is now returning for subsequent care for the nonunion. The nonunion is a complication of the fracture.
To code for fractures, the documentation should include such information as:
- Type of fracture
- Open (broken bone that penetrates the skin) or closed (broken bone that does not penetrate the skin)
- Displaced (bone breaks and moves out of alignment) or nondisplaced (bone breaks but does not move out of alignment)
- Specific anatomic site
- Routine versus delayed healing
- Episode of care: initial care, subsequent care in the healing phase, or sequela