Fraturas antigas e fraturas recentes

"Como codificar:
 Fratura antiga de L2 e
 Fratura recente do 4º arco costal direito ?"


(Responde Fernando Lopes)
 
 
A ICD-10-CM classifica as fraturas 'recentes' de modo diferenciado de acordo com o tipo de episódio de cuidados.
 
Enquanto o doente estiver a receber tratamento ativo para a fratura, codifica-se a fratura com um dos seguintes sétimos carácteres (variáveis com a categoria em que são aplicados):
A - initial encounter for closed fracture
B - initial encounter for open fracture type I or II initial encounter for open fracture NOS
C - initial encounter for open fracture type IIIA, IIIB, or IIIC
 
Entende-se como tratamento ativo:
‒ surgical treatment,
‒ emergency department encounter, and
‒ evaluation and continuing treatment by the same or a different physician (Coding Clinic)
 
Quando o doente já estiver a receber apenas tratamentos de consolidação, serão aplicáveis os seguintes sétimos carácteres:
D - subsequent encounter for closed fracture with routine healing
E - subsequent encounter for open fracture type I or II with routine healing
F - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing
G - subsequent encounter for closed fracture with delayed healing
H - subsequent encounter for open fracture type I or II with delayed healing
J - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing
K - subsequent encounter for closed fracture with nonunion
M - subsequent encounter for open fracture type I or II with nonunion
N - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion
P - subsequent encounter for closed fracture with malunion
Q - subsequent encounter for open fracture type I or II with malunion
R - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion
 
Entende-se como constituindo tratamento de consolidação:
‒ cast change or removal,
‒ an x-ray to check healing status of fracture,
‒ removal of external or internal fixation device,
‒ medication adjustment,
‒ other aftercare and follow up visits following treatment of the injury or condition (CC 1Q 2015 p.4)
 
E se o que o doente apresenta é uma sequela de uma fratura anterior, será aplicável o 7º carácter
S - sequela
 
As fraturas 'antigas' são classificadas como história de fratura com um dos seguintes códigos:
Z87.81   Personal history of (healed) traumatic fracture
Z87.310 Personal history of (healed) osteoporosis fracture
   Personal history of (healed) fragility fracture
   Personal history of (healed) collapsed vertebra due to osteoporosis 
Z87.311 Personal history of (healed) other pathological fracture
   Personal history of (healed) collapsed vertebra NOS 
   Excludes2: personal history of osteoporosis fracture (Z87.310) 
Z87.312 Personal history of (healed) stress fracture
   Personal history of (healed) fatigue fracture