Cracking the Code

Intrathoracic Injury with Rib Fracture

When reviewing medical records where the physician has documented that a patient has both an intrathoracic injury and a rib fracture, it is important to remember that the intrathoracic injury is sequenced first followed by the rib fracture diagnosis. Per instructional note for diagnosis codes that fall under the range of S22, it is advised to code first any associated injury of intrathoracic organ (S27.-) or spinal cord injury (S24.0-, S24.1-).

Q: A 64-year-old patient presents to the ED with complaints of significant pain over the left side of his body (including the shoulder and left posterior chest wall) after a fall from a ladder while painting the outside of their home. The patient was admitted for further trauma evaluation and care. The physician orders a CT of the chest, abdomen, and pelvis, and the final impression states that the patient has a comminuted nondisplaced fracture of the posterior left sixth and seventh ribs. There is also tracing of left pneumothorax.
A: S27.0XXA, traumatic pneumothorax, initial encounter
S22.42XA, multiple fractures of ribs, left side, initial encounter for closed fracture
W11.XXXA, fall on and from ladder, initial encounter
Y92.007, garden or yard of unspecified non-institutional (private) residence as the place of occurrence of the external cause
Reference: Instructional “Code First” Note under S22 (rib fractures)
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