Fracture related to combination of : Trauma and Osteoporosis

ewa_grenda@hotmail.com

I have a question to CDI / expert Coder regarding Fracture . I recently had a case with  ; Pelvic Fracture , patient had fall , also had hx of Osteoporosis - supported with CT report . After I query Physician for  - Type of FX , it was clearly documented by Physician that FX was related to : Combination of Osteoporosis and Trauma . I did change the DRG to Path FX  . After discharge this DRG was changed by the  Coder back to  Traumatic FX ( simple FX ) . After I question why was the DRG changed back to Traumatic FX  , the explanation I received from coder was , Trauma is documented in chart , and whenever Trauma is clearly documented in chart , it always has to be coded  as Traumatic type , not Osteoporotic  - type .  Is this correct , and is the a coding clinic / information  that specifies those guidelines ?

Thank you  , Eve .

rmendoza

I think it depends on the fall. If the patient fell from a stairs or ladder and sustained a fracture then that would be traumatic but if the patient fell  from a chair or any fall that would not fracture any bone , then that would be pathological(with osteo).