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Question: A patient presented to an outpatient radiology practice after suffering a fall from a stepladder while cleaning leaves from their gutters. When the patient fell from the ladder, they landed on their right wrist and were now experiencing a great deal of pain and swelling. The patient鈥檚 primary care physician (PCP) referred the patient to the radiology practice for X-rays and to assess for a fracture. The radiologist took two different views of the wrist. After reviewing the images, the radiologist shared their findings as a right displaced distal pole of scaphoid fracture.

How should this encounter be coded?

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Answer: For the imaging, you鈥檒l choose 73100 (Radiologic examination, wrist; 2 views) to report the two-view wrist X-ray. Depending on your payer鈥檚 preferences, you might also need to append modifier RT (Right side) to indicate which wrist the radiologist imaged.

Next, you鈥檒l assign S62.011A (Displaced fracture of distal pole of navicular [scaphoid] bone of right wrist, initial encounter for closed fracture) to report the radiologist鈥檚 diagnostic findings. To locate this code, you鈥檒l look for Fracture, traumatic > carpal bone(s) > navicular > distal pole (displaced) in the ICD-10-CM Alphabetic Index. When you verify the code in the Tabular List, you鈥檒l also want to note that 6^th and 7^th characters are required to complete the diagnosis code.

In this scenario, the 6^th character indicates the side of the body affected, while the 7^th character signifies the nature of the encounter and whether the fracture was open or closed. You didn鈥檛 indicate whether the fracture was open or closed, but the ICD-10-CM Official Guidelines, section I.C.19.c, state 鈥淸a] fracture not indicated as open or closed should be coded to closed.鈥�

Using 鈥淎鈥� to indicate this was an initial encounter for closed fracture as the 7^th character is, therefore, correct in this case, since the patient is seeking active treatment for the fracture and there isn鈥檛 documentation listing the fracture as open or closed.

You can also add an external cause code to the claim to indicate where or how the injury occurred. In this case, you would use W11.XXXA (Fall on and from ladder, initial encounter).

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC