Grassi Healthcare | The Importance of Documentation in Orthopedic Surgery Coding
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Healthcare Leadership Team

The Importance of Documentation in Orthopedic Surgery Coding

February 24, 2020 | Cindy Blair
Two of the most important criteria for documenting and coding any injury, fracture, and/or wound is the correct laterality and the specific site of the injury/fracture. In order to ensure proper payment for your claims and avoid denials, you as the physician must document as much information as possible so your coder can create a flawless claim. 

Specific Site of the Injury

The exact location of the injury is necessary and required for ICD-10, if known. Based on the providers exam and use of radiologic tests, the patient’s exact location of the injury can be known. This is vital information that every physician should document in their office note and/or consult. For example, if your patient arrives to their visit after sustaining a fall, you the provider determine that they have a fractured femur. After review of radiology tests, the provider determines that the patient has fractured the shaft of the femur.  This information is important not only to the coder, but also to the patient’s medical history.

Laterality and General Characteristics

Indication of the injury/fracture as to whether it is right or left is also vital information. This allows the coder to code the ICD-10 code to the highest specificity. Other characteristics that should be documented is what type of fracture occurred, i.e. displaced or non-displaced and/or closed or open. If there is no indication of the fracture being displaced or non-displaced, the coder should then choose the code as displaced. In the event the patient sustained multiple fractures, these should be sequenced by order of severity.

Documentation is a critical key point that a coder must rely on in order to code and bill a superior claim.  It’s also an important factor in keeping the patient’s medical record consistent and accurate.

For more information on ICD-10 coding compliance and maintaining revenue integrity in a value-based payment model, please contact Joe Tomaino, M.S., RN, CEO of Grassi Healthcare Advisors, at or 212.223.5020.