ICD-10 Fracture Coding

ICD-10 Fracture Coding

This month we will look at the specific requirements for proper documentation and coding of fractures under ICD-10.  Due to the specificity and number of fracture codes in ICD-10, provider documentation will be crucial in selecting the correct code.  Below is a breakdown of the information that must be documented and provided on your charge sheet in order for HCA to select the most accurate code.

Type of fracture

  • Closed or open

  • Open fractures require the Gustilo classification to be marked on the superbill and documented in the notes (Grade I, Grade II, Grade III, Grade IIIA, Grade IIIB, or Grade IIIC)

Bone alignment

  • Displaced or nondisplaced

The specific anatomical site and laterality

  • Name of the exact bone and the specific location including the right or left side of the body when appropriate

  • Ex: Fracture of 2nd  Metatarsal bone, right foot


  • Healing, routine, delayed, malunion, or nonunion

  • Document at each encounter

Episode of care

  • Initial encounter, subsequent encounter, or sequela

  • Document at each encounter

What can you do to help ensure most specific ICD-10 codes are selected?

  • Start familiarizing yourself with the new codes for your most commonly used diagnoses.

  •  Be sure to include laterality! In order to avoid unnecessary claim denials, document the condition location on both the superbill and medical record.

  • Be specific on your billing forms! The more information you provide on a billing sheet, the better chance we have of finding the most specific ICD-10 code. A condition for which you may have previously used an ICD-9 unspecified code may now be specifically coded under ICD-10. If you believe an unspecified code is still appropriate, write the condition down on the superbill so we can check.

David Swiercz