POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY

Transcription

1 POLICY TITLE ELECTRICAL BONE GROWTH STIMULATION OF THE APPENDICULAR Original Issue Date (Created): 7/1/2002 Most Recent Review Date (Revised): 6/1/2018 Effective Date: 10/1/2018 POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY I. POLICY Noninvasive electrical bone growth stimulation may be considered medically necessary as treatment of fracture s or congenital pseudoarthroses in the appendicular skeleton (the appendicular skeleton includes the bones of the shoulder girdle, upper extremities, pelvis, and lower extremities). The diagnosis of fracture must meet ALL of the following criteria: at least 3 months have passed since the date of fracture or date of surgery; serial radiographs have confirmed that no progressive signs of healing have occurred; the fracture gap is 1 cm or less; the patient can be adequately immobilized; and the patient is of an age likely to comply with non-weight bearing for fractures of the pelvis and lower extremities. Investigational applications of electrical bone growth stimulation include, but are not limited to, delayed union, fresh fracture, immediate postsurgical treatment after appendicular skeletal surgery, stress fractures, arthrodesis, or failed arthrodesis. (See Policy Guidelines for definition of delayed union.) There is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with this procedure. Implantable and semi-invasive electrical bone growth stimulators are considered investigational. There is insufficient evidence to support a conclusion concerning the health outcomes or benefits associated with these procedures. Policy Guidelines Fracture Nonunion No consensus on the definition of currently exists. One proposed definition is failure of progression of fracture healing for at least 3 consecutive months (and for at least 6 months Page 1

2 POLICY TITLE ELECTRICAL BONE GROWTH STIMULATION OF THE APPENDICULAR following the fracture), accompanied by clinical symptoms of delayed union or (pain, difficulty bearing weight) (Bhandari, 2012). The original U.S. Food and Drug Administration (FDA) labeling of fracture s defined them as fractures that had not shown progressive healing after at least 9 months from the original injury. The labeling states: A is considered to be established when a minimum of 9 months has elapsed since injury and the fracture site shows no visibly progressive signs of healing for minimum of 3 months. This timeframe is not based on physiologic principles but was included as part of the research design for FDA approval as a means of ensuring homogeneous populations of patients, many of whom were serving as their own controls. Others have contended that 9 months represents an arbitrary cutoff point that does not reflect the complicated variables that are present in fractures (i.e., degree of soft tissue damage, alignment of the bone fragments, vascularity, and quality of the underlying bone stock). Some fractures may show no signs of healing, based on serial radiographs as early as 3 months, while a fracture may not be diagnosed in others until well after 9 months. The current policy of requiring a 3-month timeframe for lack of progression of healing is consistent with the definition of as described in the clinical literature. Delayed Union Delayed union is defined as a decelerating healing process as determined by serial radiographs, together with a lack of clinical and radiologic evidence of union, bony continuity, or bone reaction at the fracture site for no less than 3 months from the index injury or the most recent intervention. In contrast, serial radiographs (described above) show no evidence of healing. When lumped together, delayed union and are sometimes referred to as ununited fractures. Fresh Fracture A fracture is most commonly defined as fresh for 7 days after its occurrence. Most fresh closed fractures heal without complications with the use of standard fracture care (i.e., closed reduction, cast immobilization). Cross-reference: MP Bone Morphogenetic Protein MP Electrical Stimulation of the Spine as an Adjunct to Spinal Fusion Procedures MP Ultrasound Accelerated Fracture Healing Device II. PRODUCT VARIATIONS TOP This policy is applicable to all programs and products administered by Capital BlueCross unless otherwise indicated below. Page 2

3 POLICY TITLE ELECTRICAL BONE GROWTH STIMULATION OF THE APPENDICULAR FEP PPO - Refer to FEP Medical Policy Manual MP , Electrical Bone Grown Stimulation of the Appendicular Skeleton. The FEP Medical Policy manual can be found at: III. DESCRIPTION/BACKGROUND TOP DELAYED FRACTURE HEALING Most bone fractures heal spontaneously over a few months postinjury. Approximately 5% to 10% of all fractures have delayed healing, resulting in continued morbidity and increased utilization of health care services. 1 There is no standard definition of a fracture. 2 The Food and Drug Administration (FDA) labeling for one of the electrical stimulators included in this review defined as follows: "A is considered to be established when a minimum of 9 months has elapsed since injury and the fracture site shows no visibly progressive signs of healing for a minimum of 3 months." Others have contended that 9 months represents an arbitrary cutoff point that does not reflect the complicated variables present in fractures (ie, the degree of soft tissue damage, alignment of the bone fragments, vascularity, quality of the underlying bone stock). Other proposed definitions of involve 3 to 6 months from the original injury, or simply when serial radiographs fail to show any further healing. According to FDA labeling for a lowintensity pulsed ultrasound device, a is considered to be established when the fracture site shows no visibly progressive signs of healing. Factors contributing to a include: which bone is fractured, fracture site, the degree of bone loss, time since injury, the extent of soft tissue injury, and patient factors (eg, smoking, diabetes, systemic disease). 1 Delayed union is generally considered a failure to heal between 3 and 9 months postfracture, after which the fracture site would be considered a. Delayed union may also be defined as a decelerating bone healing process, as identified in serial radiographs. (In contrast, serial radiographs show no evidence of healing.) Together, delayed union and are sometimes referred to as "ununited fractures." To determine fracture healing status, it is important to include both radiographic and clinical criteria. Clinical criteria include the lack of ability to bear weight, fracture pain, and tenderness on palpation. Fractures at certain locations (eg, scaphoid, proximal fifth metatarsal) are at greater risk of delayed union due to a tenuous blood supply. Systemic factors, including immunosuppression, cancer, and tobacco use, may also predispose patients to fracture, along with certain medications (eg, nonsteroidal anti-inflammatory drugs, fluoroquinolones). Treatment Individuals with recognized delayed fracture unions might begin by reducing the risk factors for delayed unions or s but may progress to surgical repair if it persists. Page 3

4 POLICY TITLE ELECTRICAL BONE GROWTH STIMULATION OF THE APPENDICULAR Electrical and Electromagnetic Bone Growth Stimulators Different applications of electrical and electromagnetic fields have been used to promote healing of delayed and fractures: invasive, noninvasive, and semi-invasive. Invasive stimulation involves the surgical implantation of a cathode at the fracture site to produce direct current electrical stimulation. Invasive devices require surgical implantation of a current generator in an intramuscular or subcutaneous space, while an electrode is implanted within the fragments of bone graft at the fusion site. The implantable device typically remains functional for 6 to 9 months after implantation, and, although the current generator is removed in a second surgical procedure when stimulation is completed, the electrode may or may not be removed. Implantable electrodes provide constant stimulation at the or fracture site but carry increased risks associated with implantable leads. Noninvasive electrical bone growth stimulators generate a weak electrical current within the target site using pulsed electromagnetic fields, capacitive coupling, or combined magnetic fields. In capacitive coupling, small skin pads/electrodes are placed on either side of the fusion site and worn for 24 hours a day until healing occurs or up to 9 months. In contrast, pulsed electromagnetic fields are delivered via treatment coils placed over the skin and worn for 6 to 8 hours a day for 3 to 6 months. Combined magnetic fields deliver a time-varying magnetic field by superimposing the time-varying magnetic field onto an additional static magnetic field. This device involves a 30-minute treatment per day for 9 months. Patient compliance may be an issue with externally worn devices. Semi-invasive (semi-implantable) stimulators use percutaneous electrodes and an external power supply, obviating the need for a surgical procedure to remove the generator when treatment is finished. REGULATORY STATUS In 1984, the noninvasive OrthoPak Bone Growth Stimulator (BioElectron, now Zimmer Biomet) was approved by FDA through the premarket approval process for treatment of fracture. Pulsed electromagnetic field systems with FDA premarket approval (all noninvasive devices) include Physio-Stim (Orthofix), first approved in 1986, and OrthoLogic 1000, approved in 1997, both indicated for treatment of established secondary to trauma, excluding vertebrae and all flat bones, in which the width of the defect is less than onehalf the width of the bone to be treated; and the EBI Bone Healing System (Electrobiology, now Zimmer Biomet), which was first approved in 1979 and indicated for s, failed fusions, and congenital pseudoarthroses. No distinction was made between long and short bones. FDA has approved labeling changes for electrical bone growth stimulators that remove any timeframe for the diagnosis. No semi-invasive electrical bone growth stimulator devices with FDA approval or clearance were identified. FDA product code LOF. Page 4

5 POLICY TITLE ELECTRICAL BONE GROWTH STIMULATION OF THE APPENDICULAR IV. RATIONALE TOP Summary of Evidence Noninvasive Electrical Bone Growth Stimulation For individuals who have fracture who receive noninvasive electrical bone growth stimulation, the evidence includes RCTs and systematic reviews of RCTs. Relevant outcomes are symptoms, change in disease status, and functional outcomes. The U.S. Food and Drug Administration has approved noninvasive electrical bone growth stimulation for fracture s and congenital pseudoarthroses in the appendicular skeleton, based largely on studies with patients serving as their controls. There is also evidence from 2 small sham-controlled randomized trials that noninvasive electrical stimulators improve fracture healing for patients with fracture. There are few nonsurgical options in this population, and the pre-post studies of patients with nonhealing fractures support the efficacy of the treatment. The evidence is sufficient to determine that the technology results in a meaningful improvement in the net health outcome. For individuals who have delayed fracture union, fresh or stress fracture(s), or who have had surgery of the appendicular skeleton who receive noninvasive electrical bone growth stimulation, the evidence includes RCTs and systematic reviews of RCTs. Relevant outcomes are symptoms, change in disease status, and functional outcomes. A meta-analysis of 5 RCTs found no statistically significant benefit of electrical bone growth stimulation for fresh fractures. RCTs on the delayed union of the other types of fractures were limited by small sample sizes and did not show significant differences in outcomes between study groups. The evidence is insufficient to determine the effects of the technology on health outcomes. Invasive Electrical Bone Growth Stimulation For individuals who have fracture, pseudoarthroses, or who have had surgery of the appendicular skeleton who receive implantable and semi-invasive electrical bone growth stimulation, the evidence includes a small number of case series. Relevant outcomes are symptoms, change in disease status, and functional outcomes. The evidence is insufficient to determine the effects of the technology on health outcomes. V. DEFINITIONS TOP APPENDICULAR consists of the bones of the limbs and their girdles, attached to the axial skeleton. AXIAL consists of bones in the head and trunk of the human body. It is composed of five parts; the human skull, the ossicles of the inner ear, the hyoid bone of the throat, the rib cage, and the vertebral column. Page 5

6 CONGENITAL PSEUDOARTHROSIS refers to a birth defect in the continuity of the tibia resulting in a separation or gap in the bone. The area is predisposed to fractures, which heal poorly. VI. BENEFIT VARIATIONS TOP The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital BlueCross for benefit information. VII. DISCLAIMER TOP Capital BlueCross medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital BlueCross considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. VIII. CODING INFORMATION TOP Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. Investigational; therefore not covered, implantable and semi-invasive electrical bone growth stimulation: CPT Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved. HCPCS Code E0749 Osteogenesis stimulator, electrical, surgically implanted Page 6

7 Covered when medically necessary, noninvasive electrical bone growth stimulation: CPT Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved. HCPCS Code E0747 Osteogenesis stimulator, electrical, noninvasive, other than spinal applications Q74.0 Other congenital malformations of upper limb(s), including shoulder girdle (includes congenital pseudarthrosis of clavicle) Q74.2 Other congenital malformations of lower limb(s), including pelvic girdle S32.311K Displaced avulsion fracture of right ilium, subsequent encounter for fracture with S32.312K Displaced avulsion fracture of left ilium, subsequent encounter for fracture with S32.314K Nondisplaced avulsion fracture of right ilium, subsequent encounter for fracture with S32.315K Nondisplaced avulsion fracture of left ilium, subsequent encounter for fracture with S32.391K Other fracture of right ilium, subsequent encounter for S32.392K Other fracture of left ilium, subsequent encounter for S32.411K Displaced fracture of anterior wall of right acetabulum, subsequent encounter for S32.412K Displaced fracture of anterior wall of left acetabulum, subsequent encounter for S32.414K Nondisplaced fracture of anterior wall of right acetabulum, subsequent encounter for S32.415K Nondisplaced fracture of anterior wall of left acetabulum, subsequent encounter for S32.421K Displaced fracture of posterior wall of right acetabulum, subsequent encounter for S32.422K Displaced fracture of posterior wall of left acetabulum, subsequent encounter for S32.424K Nondisplaced fracture of posterior wall of right acetabulum, subsequent encounter for S32.425K Nondisplaced fracture of posterior wall of left acetabulum, subsequent encounter for Page 7

8 S32.431K S32.432K S32.434K S32.435K S32.441K S32.442K S32.444K S32.445K S32.451K S32.452K S32.454K S32.455K S32.461K S32.462K S32.464K S32.465K S32.471K S32.472K S32.474K Displaced fracture of anterior column [iliopubic] of right acetabulum, subsequent encounter for Displaced fracture of anterior column [iliopubic] of left acetabulum, subsequent encounter for Nondisplaced fracture of anterior column [iliopubic] of right acetabulum, subsequent encounter for Nondisplaced fracture of anterior column [iliopubic] of left acetabulum, subsequent encounter for Displaced fracture of posterior column [ilioischial] of right acetabulum, subsequent encounter for Displaced fracture of posterior column [ilioischial] of left acetabulum, subsequent encounter for Nondisplaced fracture of posterior column [ilioischial] of right acetabulum, subsequent encounter for Nondisplaced fracture of posterior column [ilioischial] of left acetabulum, subsequent encounter for Displaced transverse fracture of right acetabulum, subsequent encounter for fracture with Displaced transverse fracture of left acetabulum, subsequent encounter for fracture with Nondisplaced transverse fracture of right acetabulum, subsequent encounter for Nondisplaced transverse fracture of left acetabulum, subsequent encounter for Displaced associated transverse-posterior fracture of right acetabulum, subsequent encounter for Displaced associated transverse-posterior fracture of left acetabulum, subsequent encounter for Nondisplaced associated transverse-posterior fracture of right acetabulum, subsequent encounter for Nondisplaced associated transverse-posterior fracture of left acetabulum, subsequent encounter for Displaced fracture of medial wall of right acetabulum, subsequent encounter for Displaced fracture of medial wall of left acetabulum, subsequent encounter for Nondisplaced fracture of medial wall of right acetabulum, subsequent encounter for Page 8

9 S32.475K S32.481K S32.482K S32.484K S32.485K S32.491K S32.492K S32.511K S32.512K S32.591K S32.592K S32.611K S32.612K S32.614K S32.615K S32.691K S32.692K S32.810K S32.811K Nondisplaced fracture of medial wall of left acetabulum, subsequent encounter for Displaced dome fracture of right acetabulum, subsequent encounter for fracture with Displaced dome fracture of left acetabulum, subsequent encounter for fracture with Nondisplaced dome fracture of right acetabulum, subsequent encounter for fracture with Nondisplaced dome fracture of left acetabulum, subsequent encounter for fracture with Other specified fracture of right acetabulum, subsequent encounter for fracture with Other specified fracture of left acetabulum, subsequent encounter for fracture with Fracture of superior rim of right pubis, subsequent encounter for fracture with Fracture of superior rim of left pubis, subsequent encounter for fracture with Other specified fracture of right pubis, subsequent encounter for fracture with Other specified fracture of left pubis, subsequent encounter for fracture with Displaced avulsion fracture of right ischium, subsequent encounter for fracture with Displaced avulsion fracture of left ischium, subsequent encounter for fracture with Nondisplaced avulsion fracture of right ischium, subsequent encounter for fracture with Nondisplaced avulsion fracture of left ischium, subsequent encounter for fracture with Other specified fracture of right ischium, subsequent encounter for fracture with Other specified fracture of left ischium, subsequent encounter for fracture with Multiple fractures of pelvis with stable disruption of pelvic ring, subsequent encounter for Multiple fractures of pelvis with unstable disruption of pelvic ring, subsequent encounter for Page 9

10 S32.82XK S32.89XK S42.011K S42.012K S42.014K S42.015K S42.017K S42.018K S42.021K S42.022K S42.024K S42.025K S42.031K S42.032K S42.034K S42.035K S42.111K S42.112K S42.114K Multiple fractures of pelvis without disruption of pelvic ring, subsequent encounter for Fracture of other parts of pelvis, subsequent encounter for Anterior displaced fracture of sternal end of right clavicle, subsequent encounter for Anterior displaced fracture of sternal end of left clavicle, subsequent encounter for Posterior displaced fracture of sternal end of right clavicle, subsequent encounter for Posterior displaced fracture of sternal end of left clavicle, subsequent encounter for Nondisplaced fracture of sternal end of right clavicle, subsequent encounter for Nondisplaced fracture of sternal end of left clavicle, subsequent encounter for Displaced fracture of shaft of right clavicle, subsequent encounter for fracture with Displaced fracture of shaft of left clavicle, subsequent encounter for fracture with Nondisplaced fracture of shaft of right clavicle, subsequent encounter for fracture with Nondisplaced fracture of shaft of left clavicle, subsequent encounter for fracture with Displaced fracture of lateral end of right clavicle, subsequent encounter for fracture with Displaced fracture of lateral end of left clavicle, subsequent encounter for fracture with Nondisplaced fracture of lateral end of right clavicle, subsequent encounter for Nondisplaced fracture of lateral end of left clavicle, subsequent encounter for Displaced fracture of body of scapula, right shoulder, subsequent encounter for Displaced fracture of body of scapula, left shoulder, subsequent encounter for Nondisplaced fracture of body of scapula, right shoulder, subsequent encounter for Page 10

11 S42.115K S42.121K S42.122K S42.124K S42.125K S42.131K S42.132K S42.134K S42.135K S42.141K S42.142K S42.144K S42.145K S42.151K S42.152K S42.154K S42.155K S42.191K S42.192K Nondisplaced fracture of body of scapula, left shoulder, subsequent encounter for Displaced fracture of acromial process, right shoulder, subsequent encounter for Displaced fracture of acromial process, left shoulder, subsequent encounter for Nondisplaced fracture of acromial process, right shoulder, subsequent encounter for Nondisplaced fracture of acromial process, left shoulder, subsequent encounter for Displaced fracture of coracoid process, right shoulder, subsequent encounter for Displaced fracture of coracoid process, left shoulder, subsequent encounter for Nondisplaced fracture of coracoid process, right shoulder, subsequent encounter for Nondisplaced fracture of coracoid process, left shoulder, subsequent encounter for Displaced fracture of glenoid cavity of scapula, right shoulder, subsequent encounter for Displaced fracture of glenoid cavity of scapula, left shoulder, subsequent encounter for Nondisplaced fracture of glenoid cavity of scapula, right shoulder, subsequent encounter for Nondisplaced fracture of glenoid cavity of scapula, left shoulder, subsequent encounter for Displaced fracture of neck of scapula, right shoulder, subsequent encounter for Displaced fracture of neck of scapula, left shoulder, subsequent encounter for Nondisplaced fracture of neck of scapula, right shoulder, subsequent encounter for Nondisplaced fracture of neck of scapula, left shoulder, subsequent encounter for Fracture of other part of scapula, right shoulder, subsequent encounter for fracture with Fracture of other part of scapula, left shoulder, subsequent encounter for fracture with Page 11

12 S42.221K S42.222K S42.224K S42.225K S42.231K S42.232K S42.241K S42.242K S42.251K S42.252K S42.254K S42.255K S42.261K S42.262K S42.264K S42.265K S42.271K S42.272K S42.291K 2-part displaced fracture of surgical neck of right humerus, subsequent encounter for 2-part displaced fracture of surgical neck of left humerus, subsequent encounter for 2-part nondisplaced fracture of surgical neck of right humerus, subsequent encounter for 2-part nondisplaced fracture of surgical neck of left humerus, subsequent encounter for 3-part fracture of surgical neck of right humerus, subsequent encounter for fracture with 3-part fracture of surgical neck of left humerus, subsequent encounter for fracture with 4-part fracture of surgical neck of right humerus, subsequent encounter for fracture with 4-part fracture of surgical neck of left humerus, subsequent encounter for fracture with Displaced fracture of greater tuberosity of right humerus, subsequent encounter for Displaced fracture of greater tuberosity of left humerus, subsequent encounter for Nondisplaced fracture of greater tuberosity of right humerus, subsequent encounter for Nondisplaced fracture of greater tuberosity of left humerus, subsequent encounter for Displaced fracture of lesser tuberosity of right humerus, subsequent encounter for Displaced fracture of lesser tuberosity of left humerus, subsequent encounter for Nondisplaced fracture of lesser tuberosity of right humerus, subsequent encounter for Nondisplaced fracture of lesser tuberosity of left humerus, subsequent encounter for Torus fracture of upper end of right humerus, subsequent encounter for fracture with Torus fracture of upper end of left humerus, subsequent encounter for fracture with Other displaced fracture of upper end of right humerus, subsequent encounter for Page 12

13 S42.292K S42.294K S42.295K S42.311K S42.312K S42.321K S42.322K S42.324K S42.325K S42.331K S42.332K S42.334K S42.335K S42.341K S42.342K S42.344K S42.345G S42.351K S42.352K Other displaced fracture of upper end of left humerus, subsequent encounter for Other nondisplaced fracture of upper end of right humerus, subsequent encounter for Other nondisplaced fracture of upper end of left humerus, subsequent encounter for Greenstick fracture of shaft of humerus, right arm, subsequent encounter for fracture with Greenstick fracture of shaft of humerus, left arm, subsequent encounter for fracture with Displaced transverse fracture of shaft of humerus, right arm, subsequent encounter for Displaced transverse fracture of shaft of humerus, left arm, subsequent encounter for Nondisplaced transverse fracture of shaft of humerus, right arm, subsequent encounter for Nondisplaced transverse fracture of shaft of humerus, left arm, subsequent encounter for Displaced oblique fracture of shaft of humerus, right arm, subsequent encounter for Displaced oblique fracture of shaft of humerus, left arm, subsequent encounter for Nondisplaced oblique fracture of shaft of humerus, right arm, subsequent encounter for Nondisplaced oblique fracture of shaft of humerus, left arm, subsequent encounter for Displaced spiral fracture of shaft of humerus, right arm, subsequent encounter for Displaced spiral fracture of shaft of humerus, left arm, subsequent encounter for Nondisplaced spiral fracture of shaft of humerus, right arm, subsequent encounter for Nondisplaced spiral fracture of shaft of humerus, left arm, subsequent encounter for fracture with delayed healing Displaced comminuted fracture of shaft of humerus, right arm, subsequent encounter for Displaced comminuted fracture of shaft of humerus, left arm, subsequent encounter for Page 13

14 S42.354K S42.355K S42.361K S42.362K S42.364K S42.365K S42.391K S42.392K S42.411K S42.412K S42.414K S42.415K S42.421K S42.422K S42.424K S42.425K S42.431K S42.432K S42.434K Nondisplaced comminuted fracture of shaft of humerus, right arm, subsequent encounter for Nondisplaced comminuted fracture of shaft of humerus, left arm, subsequent encounter for Displaced segmental fracture of shaft of humerus, right arm, subsequent encounter for Displaced segmental fracture of shaft of humerus, left arm, subsequent encounter for Nondisplaced segmental fracture of shaft of humerus, right arm, subsequent encounter for Nondisplaced segmental fracture of shaft of humerus, left arm, subsequent encounter for Other fracture of shaft of right humerus, subsequent encounter for fracture with Other fracture of shaft of left humerus, subsequent encounter for fracture with Displaced simple supracondylar fracture without intercondylar fracture of right humerus, subsequent encounter for Displaced simple supracondylar fracture without intercondylar fracture of left humerus, subsequent encounter for Nondisplaced simple supracondylar fracture without intercondylar fracture of right humerus, subsequent encounter for Nondisplaced simple supracondylar fracture without intercondylar fracture of left humerus, subsequent encounter for Displaced comminuted supracondylar fracture without intercondylar fracture of right humerus, subsequent encounter for Displaced comminuted supracondylar fracture without intercondylar fracture of left humerus, subsequent encounter for Nondisplaced comminuted supracondylar fracture without intercondylar fracture of right humerus, subsequent encounter for Nondisplaced comminuted supracondylar fracture without intercondylar fracture of left humerus, subsequent encounter for Displaced fracture (avulsion) of lateral epicondyle of right humerus, subsequent encounter for Displaced fracture (avulsion) of lateral epicondyle of left humerus, subsequent encounter for Nondisplaced fracture (avulsion) of lateral epicondyle of right humerus, subsequent encounter for Page 14

15 S42.435K S42.441K S42.442K S42.444K S42.445K S42.447K S42.448K S42.451K S42.452K S42.454K S42.455K S42.461K S42.462K S42.464K S42.465K S42.471K S42.472K S42.474K S42.475K Nondisplaced fracture (avulsion) of lateral epicondyle of left humerus, subsequent encounter for Displaced fracture (avulsion) of medial epicondyle of right humerus, subsequent encounter for Displaced fracture (avulsion) of medial epicondyle of left humerus, subsequent encounter for Nondisplaced fracture (avulsion) of medial epicondyle of right humerus, subsequent encounter for Nondisplaced fracture (avulsion) of medial epicondyle of left humerus, subsequent encounter for Incarcerated fracture (avulsion) of medial epicondyle of right humerus, subsequent encounter for Incarcerated fracture (avulsion) of medial epicondyle of left humerus, subsequent encounter for Displaced fracture of lateral condyle of right humerus, subsequent encounter for Displaced fracture of lateral condyle of left humerus, subsequent encounter for Nondisplaced fracture of lateral condyle of right humerus, subsequent encounter for Nondisplaced fracture of lateral condyle of left humerus, subsequent encounter for Displaced fracture of medial condyle of right humerus, subsequent encounter for Displaced fracture of medial condyle of left humerus, subsequent encounter for Nondisplaced fracture of medial condyle of right humerus, subsequent encounter for Nondisplaced fracture of medial condyle of left humerus, subsequent encounter for Displaced transcondylar fracture of right humerus, subsequent encounter for Displaced transcondylar fracture of left humerus, subsequent encounter for fracture with Nondisplaced transcondylar fracture of right humerus, subsequent encounter for Nondisplaced transcondylar fracture of left humerus, subsequent encounter for Page 15

16 S42.481K S42.482K S42.491K S42.492K S42.494K S42.495K S49.011K S49.012K S49.021K S49.022K S49.031K S49.032K S49.041K S49.042K S49.091K S49.092K S49.111K S49.112K S49.121K Torus fracture of lower end of right humerus, subsequent encounter for fracture with Torus fracture of lower end of left humerus, subsequent encounter for fracture with Other displaced fracture of lower end of right humerus, subsequent encounter for Other displaced fracture of lower end of left humerus, subsequent encounter for Other nondisplaced fracture of lower end of right humerus, subsequent encounter for Other nondisplaced fracture of lower end of left humerus, subsequent encounter for Salter-Harris Type I physeal fracture of upper end of humerus, right arm, subsequent encounter for Salter-Harris Type I physeal fracture of upper end of humerus, left arm, subsequent encounter for Salter-Harris Type II physeal fracture of upper end of humerus, right arm, subsequent encounter for Salter-Harris Type II physeal fracture of upper end of humerus, left arm, subsequent encounter for Salter-Harris Type III physeal fracture of upper end of humerus, right arm, subsequent encounter for Salter-Harris Type III physeal fracture of upper end of humerus, left arm, subsequent encounter for Salter-Harris Type IV physeal fracture of upper end of humerus, right arm, subsequent encounter for Salter-Harris Type IV physeal fracture of upper end of humerus, left arm, subsequent encounter for Other physeal fracture of upper end of humerus, right arm, subsequent encounter for Other physeal fracture of upper end of humerus, left arm, subsequent encounter for Salter-Harris Type I physeal fracture of lower end of humerus, right arm, subsequent encounter for Salter-Harris Type I physeal fracture of lower end of humerus, left arm, subsequent encounter for Salter-Harris Type II physeal fracture of lower end of humerus, right arm, subsequent encounter for Page 16

17 S49.122K S49.131K S49.132K S49.141K S49.142K S49.191K S49.192K S52.011K S52.012K S52.021K S52.021M S52.021N S52.022K S52.022M S52.022N S52.024K S52.024M S52.024N S52.025K Salter-Harris Type II physeal fracture of lower end of humerus, left arm, subsequent encounter for Salter-Harris Type III physeal fracture of lower end of humerus, right arm, subsequent encounter for Salter-Harris Type III physeal fracture of lower end of humerus, left arm, subsequent encounter for Salter-Harris Type IV physeal fracture of lower end of humerus, right arm, subsequent encounter for Salter-Harris Type IV physeal fracture of lower end of humerus, left arm, subsequent encounter for Other physeal fracture of lower end of humerus, right arm, subsequent encounter for Other physeal fracture of lower end of humerus, left arm, subsequent encounter for Torus fracture of upper end of right ulna, subsequent encounter for fracture with Torus fracture of upper end of left ulna, subsequent encounter for fracture with Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for closed Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for open Displaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for open Displaced fracture of olecranon process without intraarticular extension of left ulna, subsequent encounter for closed Displaced fracture of olecranon process without intraarticular extension of left ulna, subsequent encounter for open Displaced fracture of olecranon process without intraarticular extension of left ulna, subsequent encounter for open Nondisplaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for closed Nondisplaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for open Nondisplaced fracture of olecranon process without intraarticular extension of right ulna, subsequent encounter for open Nondisplaced fracture of olecranon process without intraarticular extension of left ulna, subsequent encounter for closed Page 17

18 S52.025M S52.025N S52.031K S52.031M S52.031N S52.032K S52.032M S52.032N S52.034K S52.034M S52.034N S52.035K S52.035M S52.035N S52.041K S52.041M S52.041N S52.042K S52.042M Nondisplaced fracture of olecranon process without intraarticular extension of left ulna, subsequent encounter for open Nondisplaced fracture of olecranon process without intraarticular extension of left ulna, subsequent encounter for open Displaced fracture of olecranon process with intraarticular extension of right ulna, subsequent encounter for closed Displaced fracture of olecranon process with intraarticular extension of right ulna, subsequent encounter for open Displaced fracture of olecranon process with intraarticular extension of right ulna, subsequent encounter for open Displaced fracture of olecranon process with intraarticular extension of left ulna, subsequent encounter for closed Displaced fracture of olecranon process with intraarticular extension of left ulna, subsequent encounter for open Displaced fracture of olecranon process with intraarticular extension of left ulna, subsequent encounter for open Nondisplaced fracture of olecranon process with intraarticular extension of right ulna, subsequent encounter for closed Nondisplaced fracture of olecranon process with intraarticular extension of right ulna, subsequent encounter for open Nondisplaced fracture of olecranon process with intraarticular extension of right ulna, subsequent encounter for open Nondisplaced fracture of olecranon process with intraarticular extension of left ulna, subsequent encounter for closed Nondisplaced fracture of olecranon process with intraarticular extension of left ulna, subsequent encounter for open Nondisplaced fracture of olecranon process with intraarticular extension of left ulna, subsequent encounter for open Displaced fracture of coronoid process of right ulna, subsequent encounter for closed Displaced fracture of coronoid process of right ulna, subsequent encounter for open Displaced fracture of coronoid process of right ulna, subsequent encounter for open Displaced fracture of coronoid process of left ulna, subsequent encounter for closed Displaced fracture of coronoid process of left ulna, subsequent encounter for open Page 18

19 S52.042N S52.044K S52.044M S52.044N S52.045K S52.045M S52.045N S52.091K S52.091M S52.091N S52.092K S52.092M S52.092N S52.111K S52.112K S52.121K S52.121M S52.121N S52.122K Displaced fracture of coronoid process of left ulna, subsequent encounter for open Nondisplaced fracture of coronoid process of right ulna, subsequent encounter for closed Nondisplaced fracture of coronoid process of right ulna, subsequent encounter for open Nondisplaced fracture of coronoid process of right ulna, subsequent encounter for open Nondisplaced fracture of coronoid process of left ulna, subsequent encounter for closed Nondisplaced fracture of coronoid process of left ulna, subsequent encounter for open Nondisplaced fracture of coronoid process of left ulna, subsequent encounter for open Other fracture of upper end of right ulna, subsequent encounter for closed fracture with Other fracture of upper end of right ulna, subsequent encounter for open fracture type I or II with Other fracture of upper end of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Other fracture of upper end of left ulna, subsequent encounter for closed fracture with Other fracture of upper end of left ulna, subsequent encounter for open fracture type I or II with Other fracture of upper end of left ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Torus fracture of upper end of right radius, subsequent encounter for fracture with Torus fracture of upper end of left radius, subsequent encounter for fracture with Displaced fracture of head of right radius, subsequent encounter for closed fracture with Displaced fracture of head of right radius, subsequent encounter for open fracture type I or II with Displaced fracture of head of right radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Displaced fracture of head of left radius, subsequent encounter for closed fracture with Page 19

20 S52.122M S52.122N S52.124K S52.124M S52.124N S52.125K S52.125M S52.125N S52.131K S52.131M S52.131N S52.132K S52.132M S52.132N S52.134K S52.134M S52.134N S52.135K S52.135M Displaced fracture of head of left radius, subsequent encounter for open fracture type I or II with Displaced fracture of head of left radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Nondisplaced fracture of head of right radius, subsequent encounter for closed Nondisplaced fracture of head of right radius, subsequent encounter for open Nondisplaced fracture of head of right radius, subsequent encounter for open Nondisplaced fracture of head of left radius, subsequent encounter for closed Nondisplaced fracture of head of left radius, subsequent encounter for open fracture type I or II with Nondisplaced fracture of head of left radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Displaced fracture of neck of right radius, subsequent encounter for closed fracture with Displaced fracture of neck of right radius, subsequent encounter for open fracture type I or II with Displaced fracture of neck of right radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Displaced fracture of neck of left radius, subsequent encounter for closed fracture with Displaced fracture of neck of left radius, subsequent encounter for open fracture type I or II with Displaced fracture of neck of left radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Nondisplaced fracture of neck of right radius, subsequent encounter for closed Nondisplaced fracture of neck of right radius, subsequent encounter for open Nondisplaced fracture of neck of right radius, subsequent encounter for open Nondisplaced fracture of neck of left radius, subsequent encounter for closed Nondisplaced fracture of neck of left radius, subsequent encounter for open fracture type I or II with Page 20

21 S52.135N S52.181K S52.181M S52.181N S52.182K S52.182M S52.182N S52.211K S52.212K S52.221K S52.221M S52.221N S52.222K S52.222M S52.222N S52.224K S52.224M S52.224N S52.225K Nondisplaced fracture of neck of left radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Other fracture of upper end of right radius, subsequent encounter for closed fracture with Other fracture of upper end of right radius, subsequent encounter for open fracture type I or II with Other fracture of upper end of right radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Other fracture of upper end of left radius, subsequent encounter for closed fracture with Other fracture of upper end of left radius, subsequent encounter for open fracture type I or II with Other fracture of upper end of left radius, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Greenstick fracture of shaft of right ulna, subsequent encounter for fracture with Greenstick fracture of shaft of left ulna, subsequent encounter for fracture with Displaced transverse fracture of shaft of right ulna, subsequent encounter for closed Displaced transverse fracture of shaft of right ulna, subsequent encounter for open Displaced transverse fracture of shaft of right ulna, subsequent encounter for open Displaced transverse fracture of shaft of left ulna, subsequent encounter for closed Displaced transverse fracture of shaft of left ulna, subsequent encounter for open Displaced transverse fracture of shaft of left ulna, subsequent encounter for open Nondisplaced transverse fracture of shaft of right ulna, subsequent encounter for closed Nondisplaced transverse fracture of shaft of right ulna, subsequent encounter for open Nondisplaced transverse fracture of shaft of right ulna, subsequent encounter for open Nondisplaced transverse fracture of shaft of left ulna, subsequent encounter for closed Page 21

22 S52.225M S52.225N S52.231K S52.231M S52.231N S52.232K S52.232M S52.232N S52.234K S52.234M S52.234N S52.235K S52.235M S52.235N S52.241K S52.241M S52.241N S52.242K S52.242M Nondisplaced transverse fracture of shaft of left ulna, subsequent encounter for open Nondisplaced transverse fracture of shaft of left ulna, subsequent encounter for open Displaced oblique fracture of shaft of right ulna, subsequent encounter for closed Displaced oblique fracture of shaft of right ulna, subsequent encounter for open Displaced oblique fracture of shaft of right ulna, subsequent encounter for open Displaced oblique fracture of shaft of left ulna, subsequent encounter for closed Displaced oblique fracture of shaft of left ulna, subsequent encounter for open Displaced oblique fracture of shaft of left ulna, subsequent encounter for open Nondisplaced oblique fracture of shaft of right ulna, subsequent encounter for closed Nondisplaced oblique fracture of shaft of right ulna, subsequent encounter for open Nondisplaced oblique fracture of shaft of right ulna, subsequent encounter for open Nondisplaced oblique fracture of shaft of left ulna, subsequent encounter for closed Nondisplaced oblique fracture of shaft of left ulna, subsequent encounter for open Nondisplaced oblique fracture of shaft of left ulna, subsequent encounter for open Displaced spiral fracture of shaft of ulna, right arm, subsequent encounter for closed Displaced spiral fracture of shaft of ulna, right arm, subsequent encounter for open Displaced spiral fracture of shaft of ulna, right arm, subsequent encounter for open Displaced spiral fracture of shaft of ulna, left arm, subsequent encounter for closed Displaced spiral fracture of shaft of ulna, left arm, subsequent encounter for open Page 22

23 S52.242N S52.244K S52.244M S52.244N S52.245K S52.245M S52.245N S52.251K S52.251M S52.251N S52.252K S52.252M S52.252N S52.254K S52.254M S52.254N S52.255K S52.255M S52.255N Displaced spiral fracture of shaft of ulna, left arm, subsequent encounter for open Nondisplaced spiral fracture of shaft of ulna, right arm, subsequent encounter for closed Nondisplaced spiral fracture of shaft of ulna, right arm, subsequent encounter for open Nondisplaced spiral fracture of shaft of ulna, right arm, subsequent encounter for open Nondisplaced spiral fracture of shaft of ulna, left arm, subsequent encounter for closed Nondisplaced spiral fracture of shaft of ulna, left arm, subsequent encounter for open Nondisplaced spiral fracture of shaft of ulna, left arm, subsequent encounter for open Displaced comminuted fracture of shaft of ulna, right arm, subsequent encounter for closed Displaced comminuted fracture of shaft of ulna, right arm, subsequent encounter for open Displaced comminuted fracture of shaft of ulna, right arm, subsequent encounter for open Displaced comminuted fracture of shaft of ulna, left arm, subsequent encounter for closed Displaced comminuted fracture of shaft of ulna, left arm, subsequent encounter for open Displaced comminuted fracture of shaft of ulna, left arm, subsequent encounter for open Nondisplaced comminuted fracture of shaft of ulna, right arm, subsequent encounter for closed Nondisplaced comminuted fracture of shaft of ulna, right arm, subsequent encounter for open Nondisplaced comminuted fracture of shaft of ulna, right arm, subsequent encounter for open Nondisplaced comminuted fracture of shaft of ulna, left arm, subsequent encounter for closed Nondisplaced comminuted fracture of shaft of ulna, left arm, subsequent encounter for open Nondisplaced comminuted fracture of shaft of ulna, left arm, subsequent encounter for open Page 23

24 S52.261K S52.261M S52.261N S52.262K S52.262M S52.262N S52.264K S52.264M S52.264N S52.265K S52.265M S52.265N S52.271K S52.271M S52.271N S52.272K S52.272M S52.272N S52.281K Displaced segmental fracture of shaft of ulna, right arm, subsequent encounter for closed Displaced segmental fracture of shaft of ulna, right arm, subsequent encounter for open Displaced segmental fracture of shaft of ulna, right arm, subsequent encounter for open Displaced segmental fracture of shaft of ulna, left arm, subsequent encounter for closed Displaced segmental fracture of shaft of ulna, left arm, subsequent encounter for open Displaced segmental fracture of shaft of ulna, left arm, subsequent encounter for open Nondisplaced segmental fracture of shaft of ulna, right arm, subsequent encounter for closed Nondisplaced segmental fracture of shaft of ulna, right arm, subsequent encounter for open Nondisplaced segmental fracture of shaft of ulna, right arm, subsequent encounter for open Nondisplaced segmental fracture of shaft of ulna, left arm, subsequent encounter for closed Nondisplaced segmental fracture of shaft of ulna, left arm, subsequent encounter for open Nondisplaced segmental fracture of shaft of ulna, left arm, subsequent encounter for open Monteggia's fracture of right ulna, subsequent encounter for closed fracture with Monteggia's fracture of right ulna, subsequent encounter for open fracture type I or II with Monteggia's fracture of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Monteggia's fracture of left ulna, subsequent encounter for closed fracture with Monteggia's fracture of left ulna, subsequent encounter for open fracture type I or II with Monteggia's fracture of left ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Bent bone of right ulna, subsequent encounter for closed Page 24

25 S52.281M S52.281N S52.282K S52.282M S52.282N S52.291K S52.291M S52.291N S52.292K S52.292M S52.292N S52.311K S52.312K S52.321K S52.321M S52.321N S52.322K S52.322M S52.322N Bent bone of right ulna, subsequent encounter for open fracture type I or II with Bent bone of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Bent bone of left ulna, subsequent encounter for closed Bent bone of left ulna, subsequent encounter for open fracture type I or II with Bent bone of left ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Other fracture of shaft of right ulna, subsequent encounter for closed fracture with Other fracture of shaft of right ulna, subsequent encounter for open fracture type I or II with Other fracture of shaft of right ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Other fracture of shaft of left ulna, subsequent encounter for closed fracture with Other fracture of shaft of left ulna, subsequent encounter for open fracture type I or II with Other fracture of shaft of left ulna, subsequent encounter for open fracture type IIIA, IIIB, or IIIC with Greenstick fracture of shaft of radius, right arm, subsequent encounter for fracture with Greenstick fracture of shaft of radius, left arm, subsequent encounter for fracture with Displaced transverse fracture of shaft of right radius, subsequent encounter for closed Displaced transverse fracture of shaft of right radius, subsequent encounter for open Displaced transverse fracture of shaft of right radius, subsequent encounter for open Displaced transverse fracture of shaft of left radius, subsequent encounter for closed Displaced transverse fracture of shaft of left radius, subsequent encounter for open Displaced transverse fracture of shaft of left radius, subsequent encounter for open Page 25