You would code the aftercare codes for follow up visits while the fracture is healing after the initial treatment. The guidelines state: "Fractures are coded using the aftercare codes for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase.
What are the different types of femur shaft fractures?
Fracture of femur ICD-10-CM S72. 309A is grouped within Diagnostic Related Group(s) (MS-DRG v39.0):
ICD-10-CM Code for Unspecified fracture of right femur, initial encounter for closed fracture S72. 91XA.
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In ICD-10-CM a fracture not indicated as displaced or nondisplaced should be coded to displaced, and a fracture not designated as open or closed should be coded to closed. While the classification defaults to displaced for fractures, it is very important that complete documentation is encouraged.
A broken thighbone, also known as a femur fracture, is a serious and painful injury. The femur is one of the strongest bones in the body, and a break or fracture in the femur bone is often caused by severe injury such as trauma sustained in a motor vehicle accident.
Proximal femoral fractures are a heterogeneous group of fractures that occur in and around the hip. The commonest type of fracture in this region is the femoral neck fracture. They can occur anywhere between the joint surface of the femoral head and the upper shaft (proximal diaphysis) of the femur.
Distal Femur (Thighbone) Fractures of the Knee. A fracture is a broken bone. Fractures of the thighbone that occur just above the knee joint are called distal femur fractures. The distal femur is where the bone flares out like an upside-down funnel.
Proximal femur includes the femoral head, neck and the region 5-cm distal to the lesser trochanter. There is a 125°–130° inclination angle between the head and neck and the femoral body. Further, there is a 15° anteversion angle between the plane passing through the condyles of the femoral head and the femur neck.
In this case, report ICD-10-CM codes S72. 402A (Unspecified fracture of lower end of left femur, initial encounter for closed fracture) as the principal/first listed diagnosis followed by M97. 02XA (Periprosthetic fracture around internal prosthetic left hip joint, initial encounter) as a secondary diagnosis.
Fractures are coded using the appropriate 7th character extension for subsequent care for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase.
The general consensus is to use the fracture care codes designated as “closed treatment without manipulation” and bill the initial E/M with modifier 57.
For example, ICD-10-CM code S31. 623A, Laceration with foreign body of abdominal wall, right lower quadrant with penetration into peritoneal cavity, initial encounter, shows an extension used with a laceration code. Note that in ICD-10-CM, the entire code description is written out.