PCS Coding for Ankle Fracture - Look Deeper Into the Codes!

In the musculoskeletal system, the fourth character represents the body part the procedure was performed on; the tibia in the codes below are represented here by the character G in the fourth position.

0QQG0ZZ Repair Right Tibia, Open Approach

0QQG3ZZ Repair Right Tibia, Percutaneous Approach

0QQG4ZZ Repair Right Tibia, Percutaneous Endoscopic Approach

0QQGXZZ Repair Right Tibia, External Approach

Several Approaches

There are several approaches used when coding fractures with ICD-10-PCS. The approach is the fifth character, notice the approach in the examples, O, 3, 4, and X.

• 0QQG0ZZ Repair Right Tibia, Open Approach
• 0QQG3ZZ Repair Right Tibia, Percutaneous Approach
• 0QQG4ZZ Repair Right Tibia, Percutaneous Endoscopic Approach
• 0QQGXZZ Repair Right Tibia, External Approach 

Important NOTE: An external approach is the same as a closed treatment according to the ICD-10-PCS guidelines, B5.3b Procedures performed indirectly by the application of external force through the intervening body layers are coded to the approach, external.

Example: Closed reduction of fracture is coded to the External approach.

Seven ICD-10-PCS Medical and Surgical Approaches

Not all of the following approaches apply to fractures; however, there are seven different approaches used in the medical and surgical section. 

Fixation Charges

When coding a fixation performed with the fracture, you need to remember; if the fixation was done internally it may be included with CPT and the external fixation is coded separately using the codes below.

• 20690 - Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system
  20692 - Application of a multiplane (pins or wires in more than 1 plane), unilateral, external fixation system (eg, Ilizarov, Monticelli type)
• 20696- Application of multiplane (pins or wires in more than 1 plane), unilateral, external fixation with stereotactic computer-assisted adjustment

With ICD-10-PCS, you need to look for the root operation that involves a device, the following are root operations that involve a device.

Be sure you understand the definition of each root operation for example; "Replacement" is not used to replace an External Fixation Device, even though it sounds like it should. Look at what the PCS Reference manual states:

Replacement— Root operation R

Definition: Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part

Explanation: The body part may have been taken out or replaced, or may be taken out, physically eradicated, or rendered nonfunctional during the Replacement procedure. A

Removal procedure is coded for taking out the device used in a previous replacement.

Examples: Total hip replacement, bone graft, free skin graft.

The objective of procedures coded to the root operation Replacement is to put in a device that takes the place of some or all of a body part. Replacement encompasses a wide range of procedures, from joint replacements to grafts of all kinds.

Therefore, since "Replacement" is not used to replace wires or pins, you will use "Removal" and "Insertion" procedures for removing and replacing a device used in a previous replacement procedure.

Operation P - Removal

• 0QPK04Z Removal of Int Fix from L Fibula, Open Approach

Operation H - Insertion

• 0QHK04Z Insertion of Int Fix into L Fibula, Open Approach

If just the insertion was done you would find the code under root operation H.

PCS does offer "Fusion" (Operation G). Therefore, a fusion of the ankle joint does have its own code and can be found in the lower joints section representing the fourth character.

• 0SGF05Z - Fusion of Right Ankle Joint with External Fixation Device, Open Approach

In PCS, the application of fixation of a bone has a code for each bone. You will find these codes under insertion; it is not called a fixation with PCS Coding. Remember, if you are working on a fracture, you are working with the bone, not the joint. Fusions happen on joints; insertions for a fracture are coded to the specific bone and will be found in the section under lower bones. 

We now understand that with PCS, the root operations are different than CPT; for fractures, we are coding the bone, not the joint, the Talus, along with six other bones are included with the Tarsal bone. The approach on a joint and the root operation is is not a replacement but removal and insertion.

With what you have learned in this article, find the following codes by constructing them one character at a time.  

• Fusion of Right Ankle Joint with Internal Fixation Device, Open Approach
• Repair Right Tibia, Open Approach
• Removal of Internal Fixation device from L Fibula, Open Approach
• Fusion of Right Ankle Joint with External Fixation Device, Open Approach

Codes 

0SGF04Z, 0QQG0ZZ, 0QPK04Z, 0SGF05Z