Question

A 60-year-old patient sustained a comminuted left calcaneal fracture after falling from a ladder. initial ed treatment consisted of diagnostic radiology studies and surgical orif was performed 9 days later. the patient now presents to the orthopedic clinic for evaluation and cast change. the fracture is healing normally. what icd-10-cm code(s) should be reported?

Answer 1

A comminuted fracture is a type of closed fracture wherein the bone is shattered inside the soft tissue producing multiple fragments of bone inside.  Since the history of the patient is a fall from a ladder, the corresponding ICD-10-CM code is W11.XXXD which translates to "fall on and from ladder, subsequent encounter". Since there is a calcaneal fracture (calcaneus is the bone of the sole of the foot), then the corresponding ICD-10-CM code is S92.002D which translates to "unspecified fracture of left calcaneus, subsequent encounter for fracture with routine healing".

Answer 2

The ICD-10 CM Code that should be reported is V54.19.
The reason for this is that the patient had successfully gone through and finished the treatment phase for the acute fracture. V54.19 is the accurate code that should be reported for acute fracture that has been successfully handled, this is due to the fact that, immediately a patient has complete the active phase treatment, then any additional treatment is always reported with a code range from V54.10  TO V54.19.