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Question: I have a radiology report that documents a 鈥渞edemonstration of the distal ulnar fracture fragment.鈥� Does this mean that I should assign a code for the bone fracture or report a code for a loose body in the joint?

West Virginia Subscriber

Answer: The fracture fragment documentation in the radiology report means that there is a loose body in the ulnar region. Therefore, you鈥檒l assign either M24.031 (Loose body in right wrist) or M24.032 (Loose body in left wrist), depending on which wrist was examined and diagnosed.

Locating the terms in the ICD-10-CM Alphabetic Index can be tricky since the Fracture entries don鈥檛 mention fragments or loose bodies. Instead, look to Loose > body > joint > wrist to be directed to M24.03- (Loose body in wrist) code subcategory. When you turn to the Tabular List, you鈥檒l discover a 6^th character required icon to complete the code. The 6^th character lets you specify the laterality of the condition with 鈥�1鈥� representing the right wrist, 鈥�2鈥� representing the left wrist, and 鈥�9鈥� designated for an unspecified wrist.

The term, 鈥渓oose body鈥� in the code descriptors could be used to identify bone fragments, cartilage, or both floating in the joint space. The pieces could be present due to fractures, tumors, joint disease, physical injury, or other factors.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC