An 11-year old boy with severe autism presents to the Emergency Department with a fall from a 4-5 foot round hay bale. He landed backwards on his left arm and chest two hours ago at his family’s farm. His father was present at the time of the fall and states that he did not lose consciousness, but might have “gotten the wind knocked out of him.” He got up afterwards and was ambulatory. His parents brought him in because he was not moving his left arm and was supporting it with his right arm. On examination, the left arm is minimally swollen and there is moderate pain. Pain is relieved with positioning and immobilization of the arm. The exam was difficult due to pain and the patient’s autism. Intranasal fentanyl was administered so proper assessment could be completed.
The findings from a two-view x-ray were as follows: On frontal view, there is an impacted fracture of the proximal humeral metaphysis with extension into the epiphyseal plate. On lateral view, there is transverse minimally displaced fracture with anterior angulation of the distal fragment.
Another x-ray was done that consisted of four views of the left shoulder, two views of the left elbow and three views of the left wrist. This x-ray revealed a mildly displaced fracture of the left humeral neck below the epiphyseal plate. An internal view seems to reveal an extension into the physis. There is no fat pad displacement at the elbow. The bone alignment and the joint space of the wrist are preserved. Finally, a chest x-ray was conducted and was negative.
The case was discussed with Orthopedics. They recommended a shoulder immobilizer with no reduction or surgery needed. A shoulder immobilizer was placed. A prescription for Tylenol-codeine oral liquid for pain was given to the parents. The patient was discharged and parents were instructed to follow up with the Pediatric Orthopedic Clinic within 5-7 days.
Impression: Salter-Harris type II fracture of the proximal metaphysis
of the left humerus.
Assign diagnosis codes for this Emergency Department encounter.
S49.022A Salter-Harris Type II physeal fracture of upper end of humerus, left arm, initial encounter
F84.0 Autistic disorder
W17.89XA Other fall from one level to another
Y92.79 Other farm location as the place of occurrence of the external cause
This scenario illustrates the increased specificity ICD-10 brings to the classification of fractures – in this case, Salter-Harris fractures. The Salter-Harris classification is used to describe a fracture of the growth plate of the bone. Growth plate fractures occur in bones that are not fully grown. At that point, the growth plates are still open and filled with cartilaginous tissue.
Fractures using the Salter-Harris classification for growth plate fractures can be found in the following categories:
• Humerus – S49
• Ulna and radius – S59
• Femur – S79
• Tibia and fibular – S89
The five Salter Harris fracture classifications are as follow:
• Type 1 describes fractures that go across the growth plate – the physis.
• Type 2 designates fractures involving both the growth plate and metaphysis – the epiphysis is not involved.
• Type 3 classifies fractures involving both the growth plate and the epiphysis.
• Type 4 is a fracture involving the growth plate, the metaphysis, and the epiphysis.
• Type 5 is a compression fracture of the growth plate resulting in a decrease in the perceived space between the epiphysis and diaphysis on x-ray.
It’s important to note that ICD-10-CM does not separately classify Type 5. If the physician documents a Salter-Harris Type 5 physeal (growth plate) fracture of the lower end of the right humerus, then S49.191_, Other physeal fracture of lower end of humerus, right arm, would be assigned.
For this scenario, code S49.022A, Salter-Harris Type II physeal fracture of upper end of humerus, left arm, initial encounter, is assigned.
The external cause code assigned to this scenario is W17.89XA. Other fall from one level to another, initial encounter. Code Y92.79, Other farm location as the place of occurrence of the external cause is assigned as well. Some of you assigned codes Y93.9, Unspecified activity, and Y99.9, Unspecified external cause status to this scenario. Remember that the 2015 ICD-10-CM Official Guidelines for Coding and Reporting state that you should not assign codes for these when the activity and/or the status is not stated (see guidelines 20.c. and 20.k., respectively). Neither the activity nor the status was stated in this scenario.
Lastly, code F84.0, Autistic disorder, should be assigned for this scenario as well.
Sue Belley is a project manager with the consulting services business of 3M Health Information Systems.