Open fracture of sacrum and coccyx without mention of spinal cord injury

This code signifies a break in the sacrum or coccyx that has compromised the skin, exposing the bone to the external environment. It specifically indicates that there is no associated damage to the spinal cord. This type of injury carries a higher risk of infection compared to closed fractures.

Apply this code when documentation clearly states an open fracture involving the sacrum or coccyx. This would typically be seen in trauma cases, such as falls or motor vehicle accidents, where there is a visible wound communicating with the fracture site. Physician notes should explicitly mention the open nature of the fracture and the specific bone(s) involved.

• Ensure documentation specifies "open" to differentiate from closed fractures of the sacrum/coccyx.
• Verify that there is no mention of spinal cord injury; if present, a different code would be required.
• Always sequence this code as a primary diagnosis when it is the reason for the encounter.