As Medical Coders we need to be very familiar with the language of Medicine.
That said, you need not be intimidated by the vast expanse of Medical Terms and Slangs. There is no need to memorize all of the terms. But you should at least be able to maneuver your way through the Medical Chart and understand the diagnosis and the procedures performed by the physician for the patient.
Unless you accurately understand and analyse what has been done you will not be able to select the correct code. So I am enclosing below some of the common terms you will find often in fracture Coding. These terms are often seen in the CPC exam too!
The terms "closed treatment," "open treatment," and "percutaneous skeletal fixation" have been carefully chosen to accurately reflect current orthopedic procedural treatments.
Closed treatment specifically means that the fracture site is not surgically opened (exposed to the external environment and directly visualized). This terminology is used to describe procedures that treat fractures by three methods: (1) without manipulation; (2) with manipulation; or (3) with or without traction.
Open treatment is used when the fractured bone is either: (1) surgically opened (exposed to the external environment) and the fracture (bone ends) visualized and internal fixation may be used; or (2) the fractured bone is opened remote from the fracture site in order to insert an intramedullary nail across the fracture site (the fracture site is not opened and visualized).
Percutaneous skeletal fixation describes fracture treatment which is neither open nor closed. In this procedure, the fracture fragments are not visualized, but fixation (eg, pins) is placed across the fracture site, usually under X-ray imaging.
The type of fracture (eg, open, compound, closed) does not have any coding correlation with the type of treatment (eg, closed, open, or percutaneous) provided.
The codes for treatment of fractures and joint injuries (dislocations) are categorized by the type of manipulation (reduction) and stabilization (fixation or immobilization). These codes can apply to either open (compound) or closed fractures or joint injuries.
Skeletal traction is the application of a force (distracting or traction force) to a limb segment through a wire, pin, screw, or clamp that is attached (eg, penetrates) to bone.
Skin traction is the application of a force (longitudinal) to a limb using felt or strapping applied directly to skin only.
External fixation is the usage of skeletal pins plus an attaching mechanism/device used for temporary or definitive treatment of acute or chronic bony deformity.
Codes for obtaining autogenous bone grafts, cartilage, tendon, fascia lata grafts or other tissues through separate incisions are to be used only when the graft is not already listed as part of the basic procedure.
Re-reduction of a fracture and/or dislocation performed by the primary physician or other qualified health care professional may be identified by the addition of modifier 76 to the usual procedure number to indicate "Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional." (See Appendix A guidelines.)
Codes for external fixation are to be used only when external fixation is not already listed as part of the basic procedure.
Manipulation is used throughout the musculoskeletal fracture and dislocation subsections to specifically mean the attempted reduction or restoration of a fracture or joint dislocation to its normal anatomic alignment by the application of manually applied forces.
Excision of subcutaneous soft connective tissue tumors (including simple or intermediate repair) involves the simple or marginal resection of tumors confined to subcutaneous tissue below the skin but above the deep fascia. These tumors are usually benign and are resected without removing a significant amount of surrounding normal tissue. Code selection is based on the location and size of the tumor. Code selection is determined by measuring the greatest diameter of the tumor plus that margin required for complete excision of the tumor. The margins refer to the most narrow margin required to adequately excise the tumor, based on the physician's judgment. The measurement of the tumor plus margin is made at the time of the excision. Appreciable vessel exploration and/or neuroplasty should be reported separately. Extensive undermining or other techniques to close a defect created by skin excision may require a complex repair which should be reported separately. Dissection or elevation of tissue planes to permit resection of the tumor is included in the excision. For excision of benign lesions of cutaneous origin (eg, sebaceous cyst)
Excision of fascial or subfascial soft tissue tumors (including simple or intermediate repair) involves the resection of tumors confined to the tissue within or below the deep fascia, but not involving the bone. These tumors are usually benign, are often intramuscular, and are resected without removing a significant amount of surrounding normal tissue. Code selection is based on size and location of the tumor. Code selection is determined by measuring the greatest diameter of the tumor plus that margin required for complete excision of the tumor. The margins refer to the most narrow margin required to adequately excise the tumor, based on individual judgment. The measurement of the tumor plus margin is made at the time of the excision. Appreciable vessel exploration and/or neuroplasty should be reported separately. Extensive undermining or other techniques to close a defect created by skin excision may require a complex repair which should be reported separately. Dissection or elevation of tissue planes to permit resection of the tumor is included in the excision.
Digital (ie, fingers and toes) subfascial tumors are defined as those tumors involving the tendons, tendon sheaths, or joints of the digit. Tumors which simply abut but do not breach the tendon, tendon sheath, or joint capsule are considered subcutaneous soft tissue tumors.
Radical resection of soft connective tissue tumors (including simple or intermediate repair) involves the resection of the tumor with wide margins of normal tissue. Appreciable vessel exploration and/or neuroplasty repair or reconstruction (eg, adjacent tissue transfer[s], flap[s]) should be reported separately. Extensive undermining or other techniques to close a defect created by skin excision may require a complex repair which should be reported separately. Dissection or elevation of tissue planes to permit resection of the tumor is included in the excision. Although these tumors may be confined to a specific layer (eg, subcutaneous, subfascial), radical resection may involve removal of tissue from one or more layers. Radical resection of soft tissue tumors is most commonly used for malignant connective tissue tumors or very aggressive benign connective tissue tumors. Code selection is based on size and location of the tumor. Code selection is determined by measuring the greatest diameter of the tumor plus that margin required for complete excision of the tumor. The margins refer to the most narrow margin required to adequately excise the tumor, based on individual judgment. The measurement of the tumor plus margin is made at the time of the excision. For radical resection of tumor(s) of cutaneous origin (eg, melanoma).
Radical resection of bone tumors (including simple or intermediate repair) involves the resection of the tumor with wide margins of normal tissue. Appreciable vessel exploration and/or neuroplasty and complex bone repair or reconstruction (eg, adjacent tissue transfer[s], flap[s]) should be reported separately. Extensive undermining or other techniques to close a defect created by skin excision may require a complex repair which should be reported separately. Dissection or elevation of tissue planes to permit resection of the tumor is included in the excision. It may require removal of the entire bone if tumor growth is extensive (eg, clavicle). Radical resection of bone tumors is usually performed for malignant tumors or very aggressive benign tumors. If surrounding soft tissue is removed during these procedures, the radical resection of soft tissue tumor codes should not be reported separately. Code selection is based solely on the location of the tumor, not on the size of the tumor or whether the tumor is benign or malignant, primary or metastatic.
That said, you need not be intimidated by the vast expanse of Medical Terms and Slangs. There is no need to memorize all of the terms. But you should at least be able to maneuver your way through the Medical Chart and understand the diagnosis and the procedures performed by the physician for the patient.
Unless you accurately understand and analyse what has been done you will not be able to select the correct code. So I am enclosing below some of the common terms you will find often in fracture Coding. These terms are often seen in the CPC exam too!
The terms "closed treatment," "open treatment," and "percutaneous skeletal fixation" have been carefully chosen to accurately reflect current orthopedic procedural treatments.
Closed treatment specifically means that the fracture site is not surgically opened (exposed to the external environment and directly visualized). This terminology is used to describe procedures that treat fractures by three methods: (1) without manipulation; (2) with manipulation; or (3) with or without traction.
Open treatment is used when the fractured bone is either: (1) surgically opened (exposed to the external environment) and the fracture (bone ends) visualized and internal fixation may be used; or (2) the fractured bone is opened remote from the fracture site in order to insert an intramedullary nail across the fracture site (the fracture site is not opened and visualized).
Percutaneous skeletal fixation describes fracture treatment which is neither open nor closed. In this procedure, the fracture fragments are not visualized, but fixation (eg, pins) is placed across the fracture site, usually under X-ray imaging.
The type of fracture (eg, open, compound, closed) does not have any coding correlation with the type of treatment (eg, closed, open, or percutaneous) provided.
The codes for treatment of fractures and joint injuries (dislocations) are categorized by the type of manipulation (reduction) and stabilization (fixation or immobilization). These codes can apply to either open (compound) or closed fractures or joint injuries.
Skeletal traction is the application of a force (distracting or traction force) to a limb segment through a wire, pin, screw, or clamp that is attached (eg, penetrates) to bone.
Skin traction is the application of a force (longitudinal) to a limb using felt or strapping applied directly to skin only.
External fixation is the usage of skeletal pins plus an attaching mechanism/device used for temporary or definitive treatment of acute or chronic bony deformity.
Codes for obtaining autogenous bone grafts, cartilage, tendon, fascia lata grafts or other tissues through separate incisions are to be used only when the graft is not already listed as part of the basic procedure.
Re-reduction of a fracture and/or dislocation performed by the primary physician or other qualified health care professional may be identified by the addition of modifier 76 to the usual procedure number to indicate "Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional." (See Appendix A guidelines.)
Codes for external fixation are to be used only when external fixation is not already listed as part of the basic procedure.
Manipulation is used throughout the musculoskeletal fracture and dislocation subsections to specifically mean the attempted reduction or restoration of a fracture or joint dislocation to its normal anatomic alignment by the application of manually applied forces.
Excision of subcutaneous soft connective tissue tumors (including simple or intermediate repair) involves the simple or marginal resection of tumors confined to subcutaneous tissue below the skin but above the deep fascia. These tumors are usually benign and are resected without removing a significant amount of surrounding normal tissue. Code selection is based on the location and size of the tumor. Code selection is determined by measuring the greatest diameter of the tumor plus that margin required for complete excision of the tumor. The margins refer to the most narrow margin required to adequately excise the tumor, based on the physician's judgment. The measurement of the tumor plus margin is made at the time of the excision. Appreciable vessel exploration and/or neuroplasty should be reported separately. Extensive undermining or other techniques to close a defect created by skin excision may require a complex repair which should be reported separately. Dissection or elevation of tissue planes to permit resection of the tumor is included in the excision. For excision of benign lesions of cutaneous origin (eg, sebaceous cyst)
Excision of fascial or subfascial soft tissue tumors (including simple or intermediate repair) involves the resection of tumors confined to the tissue within or below the deep fascia, but not involving the bone. These tumors are usually benign, are often intramuscular, and are resected without removing a significant amount of surrounding normal tissue. Code selection is based on size and location of the tumor. Code selection is determined by measuring the greatest diameter of the tumor plus that margin required for complete excision of the tumor. The margins refer to the most narrow margin required to adequately excise the tumor, based on individual judgment. The measurement of the tumor plus margin is made at the time of the excision. Appreciable vessel exploration and/or neuroplasty should be reported separately. Extensive undermining or other techniques to close a defect created by skin excision may require a complex repair which should be reported separately. Dissection or elevation of tissue planes to permit resection of the tumor is included in the excision.
Digital (ie, fingers and toes) subfascial tumors are defined as those tumors involving the tendons, tendon sheaths, or joints of the digit. Tumors which simply abut but do not breach the tendon, tendon sheath, or joint capsule are considered subcutaneous soft tissue tumors.
Radical resection of soft connective tissue tumors (including simple or intermediate repair) involves the resection of the tumor with wide margins of normal tissue. Appreciable vessel exploration and/or neuroplasty repair or reconstruction (eg, adjacent tissue transfer[s], flap[s]) should be reported separately. Extensive undermining or other techniques to close a defect created by skin excision may require a complex repair which should be reported separately. Dissection or elevation of tissue planes to permit resection of the tumor is included in the excision. Although these tumors may be confined to a specific layer (eg, subcutaneous, subfascial), radical resection may involve removal of tissue from one or more layers. Radical resection of soft tissue tumors is most commonly used for malignant connective tissue tumors or very aggressive benign connective tissue tumors. Code selection is based on size and location of the tumor. Code selection is determined by measuring the greatest diameter of the tumor plus that margin required for complete excision of the tumor. The margins refer to the most narrow margin required to adequately excise the tumor, based on individual judgment. The measurement of the tumor plus margin is made at the time of the excision. For radical resection of tumor(s) of cutaneous origin (eg, melanoma).
Radical resection of bone tumors (including simple or intermediate repair) involves the resection of the tumor with wide margins of normal tissue. Appreciable vessel exploration and/or neuroplasty and complex bone repair or reconstruction (eg, adjacent tissue transfer[s], flap[s]) should be reported separately. Extensive undermining or other techniques to close a defect created by skin excision may require a complex repair which should be reported separately. Dissection or elevation of tissue planes to permit resection of the tumor is included in the excision. It may require removal of the entire bone if tumor growth is extensive (eg, clavicle). Radical resection of bone tumors is usually performed for malignant tumors or very aggressive benign tumors. If surrounding soft tissue is removed during these procedures, the radical resection of soft tissue tumor codes should not be reported separately. Code selection is based solely on the location of the tumor, not on the size of the tumor or whether the tumor is benign or malignant, primary or metastatic.
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