ICD-10: Clinical Concepts for Orthopedics

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ICD-10 Clinical Concepts Series

ICD-10 Common Codes for Orthopedics is a feature of Road to 10, a CMS online tool built with physician input.

ICD-10

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ICD-10 Compliance Date: October 1, 2015

Clinical Concepts for Orthopedics

Common Codes

Clinical Documentation Tips

Clinical Scenarios

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• Scenario 1: Fracture Follow-Up Visit

• Scenario 2: Shoulder ROM Office Visit

• Scenario 3: Tear of Medial Meniscus With Anterior Cruciate Ligament Injury

• Scenario: Cervical Disc Disease

• Scenario: Struck by Car

• Scenario: Fracture

Clinical Scenarios

Table Of ContentsCommon Codes


• Cervical Spine Disorders and Displacement

• Neck and Back Pain

• Osteoarthritis of the Hip

• Osteoarthritis of the Knee

• Radiculopathy (Primary)

• Rheumatoid Arthritis

• Selected Shoulder Conditions

• Spinal Stenosis of the Lumbar Region

• Selected Sprains – Rotator Cuff, Cruciate Ligament, and Ankle

• Thoracic, Thoracolumbar, and Lumbosacral Intervertebral Disc Disorders

• Fractures

• Arthritis

• Injuries

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Common Codes


M50.00* Cervicaldiscdisorderwithmyelopathy,unspecifiedcervicalregionM50.01 Cervicaldiscdisorderwithmyelopathy,occipito-atlanto-axialregionM50.02 Cervicaldiscdisorderwithmyelopathy,mid-cervicalregionM50.03 Cervicaldiscdisorderwithmyelopathy,cervicothoracicregionM50.10* Cervicaldiscdisorderwithradiculopathy,unspecifiedcervicalregionM50.11 Cervicaldiscdisorderwithradiculopathy,occipito-atlanto-axialregionM50.12 Cervicaldiscdisorderwithradiculopathy,mid-cervicalregionM50.13 Cervicaldiscdisorderwithradiculopathy,cervicothoracicregionM50.20* Othercervicaldiscdisplacement,unspecifiedcervicalregionM50.21 Othercervicaldiscdisplacement,occipito-atlanto-axialregionM50.22 Othercervicaldiscdisplacement,mid-cervicalregionM50.23 Othercervicaldiscdisplacement,cervicothoracicregionM50.30* Othercervicaldiscdegeneration,unspecifiedcervicalregionM50.31 Othercervicaldiscdegeneration,occipito-atlanto-axialregionM50.32 Othercervicaldiscdegeneration,mid-cervicalregionM50.33 Othercervicaldiscdegeneration,cervicothoracicregionM50.80* Othercervicaldiscdisorders,unspecifiedcervicalregionM50.81 Othercervicaldiscdisorders,occipito-atlanto-axialregionM50.82 Othercervicaldiscdisorders,mid-cervicalregionM50.83 Othercervicaldiscdisorders,cervicothoracicregionM50.90* Cervicaldiscdisorder,unspecified,unspecifiedcervicalregionM50.91 Cervicaldiscdisorder,unspecified,occipito-atlanto-axialregionM50.92 Cervicaldiscdisorder,unspecified,mid-cervicalregionM50.93 Cervicaldiscdisorder,unspecified,cervicothoracicregion

Cervical Spine Disorders and Displacement (ICD-9-CM 722.0, 722.4, 722.71, 722.91, 723.4)

*Codeswithagreaterdegreeofspecificityshouldbeconsideredfirst.

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M54.2 CervicalgiaM54.30* Sciatica,unspecifiedsideM54.31 Sciatica,rightsideM54.32 Sciatica,leftsideM54.40* Lumbagowithsciatica,unspecifiedsideM54.41 Lumbagowithsciatica,rightsideM54.42 Lumbagowithsciatica,leftsideM54.5 LowbackpainM54.6 Pain in thoracic spineM54.89 OtherdorsalgiaM54.9* Dorsalgia,unspecified

M16.0 BilateralprimaryosteoarthritisofhipM16.10* Unilateralprimaryosteoarthritis,unspecifiedhipM16.11 Unilateralprimaryosteoarthritis,righthipM16.12 Unilateralprimaryosteoarthritis,lefthipM16.2 BilateralosteoarthritisresultingfromhipdysplasiaM16.30* Unilateralosteoarthritisresultingfromhipdysplasia,unspecifiedhipM16.31 Unilateralosteoarthritisresultingfromhipdysplasia,righthipM16.32 Unilateralosteoarthritisresultingfromhipdysplasia,lefthipM16.4 Bilateralpost-traumaticosteoarthritisofhipM16.50* Unilateralpost-traumaticosteoarthritis,unspecifiedhipM16.51 Unilateralpost-traumaticosteoarthritis,righthipM16.52 Unilateralpost-traumaticosteoarthritis,lefthipM16.6 OtherbilateralsecondaryosteoarthritisofhipM16.7 OtherunilateralsecondaryosteoarthritisofhipM16.9* Osteoarthritisofhip,unspecified

Neck and Back Pain (ICD-9-CM 723.1, 724.1, 724.2, 724.3, 724.5)

Osteoarthritis of the Hip (ICD-9-CM 715.15, 715.25, 715.35, 715.95)



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M17.0 BilateralprimaryosteoarthritisofkneeM17.10* Unilateralprimaryosteoarthritis,unspecifiedkneeM17.11 Unilateralprimaryosteoarthritis,rightkneeM17.12 Unilateralprimaryosteoarthritis,leftkneeM17.2 Bilateralpost-traumaticosteoarthritisofkneeM17.30* Unilateralpost-traumaticosteoarthritis,unspecifiedkneeM17.31 Unilateralpost-traumaticosteoarthritis,rightkneeM17.32 Unilateralpost-traumaticosteoarthritis,leftkneeM17.4 OtherbilateralsecondaryosteoarthritisofkneeM17.5 OtherunilateralsecondaryosteoarthritisofkneeM17.9* Osteoarthritisofknee,unspecified

M54.10* Radiculopathy,siteunspecifiedM54.11 Radiculopathy,occipito-atlanto-axialregionM54.12 Radiculopathy,cervicalregionM54.13 Radiculopathy,cervicothoracicregionM54.14 Radiculopathy,thoracicregionM54.15 Radiculopathy,thoracolumbarregionM54.16 Radiculopathy,lumbarregionM54.17 Radiculopathy,lumbosacralregionM54.18 Radiculopathy,sacralandsacrococcygealregionM54.30* Sciatica,unspecifiedsideM54.31 Sciatica,rightsideM54.32 Sciatica,leftside

Osteoarthritis of the Knee (ICD-9-CM 715.16, 715.26, 715.36, 715.96)

Radiculopathy (Primary) (ICD-9-CM 723.4, 724.3, 724.4, 729.2)



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M05.611 Rheumatoidarthritisofrightshoulderwithinvolvementofother organsandsystemsM05.612 Rheumatoidarthritisofleftshoulderwithinvolvementofother organsandsystemsM05.619* Rheumatoidarthritisofunspecifiedshoulderwithinvolvement ofotherorgansandsystemsM05.621 Rheumatoidarthritisofrightelbowwithinvolvementofother organsandsystemsM05.622 Rheumatoidarthritisofleftelbowwithinvolvementofother organsandsystemsM05.629* Rheumatoidarthritisofunspecifiedelbowwithinvolvement ofotherorgansandsystemsM05.631 Rheumatoidarthritisofrightwristwithinvolvementofother organsandsystemsM05.632 Rheumatoidarthritisofleftwristwithinvolvementofotherorgans and systemsM05.639* Rheumatoidarthritisofunspecifiedwristwithinvolvementofother organsandsystemsM05.641 Rheumatoidarthritisofrighthandwithinvolvementofotherorgans and systemsM05.642 Rheumatoidarthritisoflefthandwithinvolvementofotherorgans and systemsM05.649* Rheumatoidarthritisofunspecifiedhandwithinvolvementofother organsandsystemsM05.651 Rheumatoidarthritisofrighthipwithinvolvementofotherorgans and systemsM05.652 Rheumatoidarthritisoflefthipwithinvolvementofotherorgans and systemsM05.659* Rheumatoidarthritisofunspecifiedhipwithinvolvementofother organsandsystemsM05.661 Rheumatoidarthritisofrightkneewithinvolvementofotherorgans and systems

Rheumatoid Arthritis (ICD-9-CM 714.0, 714.2)Excludes Combination Codes that Include Neuropathy, Bursitis and Nodule Codes, and the Codes that Indicate “Unspecified Site”.


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M05.662 Rheumatoidarthritisofleftkneewithinvolvementofotherorgans and systemsM05.669* Rheumatoidarthritisofunspecifiedkneewithinvolvementofother organsandsystemsM05.671 Rheumatoidarthritisofrightankleandfootwithinvolvementof otherorgansandsystemsM05.672 Rheumatoidarthritisofleftankleandfootwithinvolvementof otherorgansandsystemsM05.679* Rheumatoidarthritisofunspecifiedankleandfootwithinvolvement ofotherorgansandsystemsM05.69 Rheumatoidarthritisofmultiplesiteswithinvolvementofother organsandsystemsM05.711 Rheumatoidarthritiswithrheumatoidfactorofrightshoulderwithout organorsystemsinvolvementM05.712 Rheumatoidarthritiswithrheumatoidfactorofleftshoulderwithout organorsystemsinvolvementM05.719* Rheumatoidarthritiswithrheumatoidfactorofunspecifiedshoulder withoutorganorsystemsinvolvementM05.721 Rheumatoidarthritiswithrheumatoidfactorofrightelbowwithout organorsystemsinvolvementM05.722 Rheumatoidarthritiswithrheumatoidfactorofleftelbowwithout organorsystemsinvolvementM05.729* Rheumatoidarthritiswithrheumatoidfactorofunspecifiedelbow withoutorganorsystemsinvolvementM05.731 Rheumatoidarthritiswithrheumatoidfactorofrightwristwithout organorsystemsinvolvementM05.732 Rheumatoidarthritiswithrheumatoidfactorofleftwristwithoutorgan or systems involvementM05.739* Rheumatoidarthritiswithrheumatoidfactorofunspecifiedwrist withoutorganorsystemsinvolvementM05.741 Rheumatoidarthritiswithrheumatoidfactorofrighthandwithout organorsystemsinvolvement

Rheumatoid Arthritis (ICD-9-CM 714.0, 714.2)Excludes Combination Codes that Include Neuropathy, Bursitis and Nodule Codes, and the Codes that Indicate “Unspecified Site”. (continued)


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M05.742 Rheumatoidarthritiswithrheumatoidfactoroflefthandwithoutorgan or systems involvementM05.749* Rheumatoidarthritiswithrheumatoidfactorofunspecifiedhand withoutorganorsystemsinvolvementM05.751 Rheumatoidarthritiswithrheumatoidfactorofrighthipwithoutorgan or systems involvementM05.752 Rheumatoidarthritiswithrheumatoidfactoroflefthipwithoutorgan or systems involvementM05.759* Rheumatoidarthritiswithrheumatoidfactorofunspecifiedhipwithout organorsystemsinvolvementM05.761 Rheumatoidarthritiswithrheumatoidfactorofrightkneewithoutorgan or systems involvementM05.762 Rheumatoidarthritiswithrheumatoidfactorofleftkneewithoutorgan or systems involvementM05.769* Rheumatoidarthritiswithrheumatoidfactorofunspecifiedkneewithout organorsystemsinvolvementM05.771 Rheumatoidarthritiswithrheumatoidfactorofrightankleandfootwithout organorsystemsinvolvementM05.772 Rheumatoidarthritiswithrheumatoidfactorofleftankleandfootwithout organorsystemsinvolvementM05.779* Rheumatoidarthritiswithrheumatoidfactorofunspecifiedankleandfoot withoutorganorsystemsinvolvementM05.79 Rheumatoidarthritiswithrheumatoidfactorofmultiplesiteswithoutorgan or systems involvementM05.811 OtherrheumatoidarthritiswithrheumatoidfactorofrightshoulderM05.812 OtherrheumatoidarthritiswithrheumatoidfactorofleftshoulderM05.819* OtherrheumatoidarthritiswithrheumatoidfactorofunspecifiedshoulderM05.821 OtherrheumatoidarthritiswithrheumatoidfactorofrightelbowM05.822 OtherrheumatoidarthritiswithrheumatoidfactorofleftelbowM05.829* OtherrheumatoidarthritiswithrheumatoidfactorofunspecifiedelbowM05.831 OtherrheumatoidarthritiswithrheumatoidfactorofrightwristM05.832 Otherrheumatoidarthritiswithrheumatoidfactorofleftwrist



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M05.839* OtherrheumatoidarthritiswithrheumatoidfactorofunspecifiedwristM05.841 OtherrheumatoidarthritiswithrheumatoidfactorofrighthandM05.842 OtherrheumatoidarthritiswithrheumatoidfactoroflefthandM05.849* OtherrheumatoidarthritiswithrheumatoidfactorofunspecifiedhandM05.851 OtherrheumatoidarthritiswithrheumatoidfactorofrighthipM05.852 OtherrheumatoidarthritiswithrheumatoidfactoroflefthipM05.859* OtherrheumatoidarthritiswithrheumatoidfactorofunspecifiedhipM05.861 OtherrheumatoidarthritiswithrheumatoidfactorofrightkneeM05.862 OtherrheumatoidarthritiswithrheumatoidfactorofleftkneeM05.869* OtherrheumatoidarthritiswithrheumatoidfactorofunspecifiedkneeM05.871 OtherrheumatoidarthritiswithrheumatoidfactorofrightankleandfootM05.872 OtherrheumatoidarthritiswithrheumatoidfactorofleftankleandfootM05.879* Otherrheumatoidarthritiswithrheumatoidfactorofunspecified ankleandfootM05.89 OtherrheumatoidarthritiswithrheumatoidfactorofmultiplesitesM05.9* Rheumatoidarthritiswithrheumatoidfactor,unspecifiedM06.00* Rheumatoidarthritiswithoutrheumatoidfactor,unspecifiedsiteM06.011 Rheumatoidarthritiswithoutrheumatoidfactor,rightshoulderM06.012 Rheumatoidarthritiswithoutrheumatoidfactor,leftshoulderM06.019* Rheumatoidarthritiswithoutrheumatoidfactor,unspecifiedshoulderM06.021 Rheumatoidarthritiswithoutrheumatoidfactor,rightelbowM06.022 Rheumatoidarthritiswithoutrheumatoidfactor,leftelbowM06.029* Rheumatoidarthritiswithoutrheumatoidfactor,unspecifiedelbowM06.031 Rheumatoidarthritiswithoutrheumatoidfactor,rightwristM06.032 Rheumatoidarthritiswithoutrheumatoidfactor,leftwristM06.039* Rheumatoidarthritiswithoutrheumatoidfactor,unspecifiedwristM06.041 Rheumatoidarthritiswithoutrheumatoidfactor,righthandM06.042 Rheumatoidarthritiswithoutrheumatoidfactor,lefthandM06.049* Rheumatoidarthritiswithoutrheumatoidfactor,unspecifiedhandM06.051 Rheumatoidarthritiswithoutrheumatoidfactor,righthipM06.052 Rheumatoidarthritiswithoutrheumatoidfactor,lefthipM06.059* Rheumatoidarthritiswithoutrheumatoidfactor,unspecifiedhipM06.061 Rheumatoidarthritiswithoutrheumatoidfactor,rightknee



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M06.062 Rheumatoidarthritiswithoutrheumatoidfactor,leftkneeM06.069* Rheumatoidarthritiswithoutrheumatoidfactor,unspecifiedkneeM06.071 Rheumatoidarthritiswithoutrheumatoidfactor,rightankleandfootM06.072 Rheumatoidarthritiswithoutrheumatoidfactor,leftankleandfootM06.079* Rheumatoidarthritiswithoutrheumatoidfactor,unspecifiedankleandfootM06.08 Rheumatoidarthritiswithoutrheumatoidfactor,vertebraeM06.09 Rheumatoidarthritiswithoutrheumatoidfactor,multiplesitesM06.80* Otherspecifiedrheumatoidarthritis,unspecifiedsiteM06.811 Otherspecifiedrheumatoidarthritis,rightshoulderM06.812 Otherspecifiedrheumatoidarthritis,leftshoulderM06.819* Otherspecifiedrheumatoidarthritis,unspecifiedshoulderM06.821 Otherspecifiedrheumatoidarthritis,rightelbowM06.822 Otherspecifiedrheumatoidarthritis,leftelbowM06.829* Otherspecifiedrheumatoidarthritis,unspecifiedelbowM06.831 Otherspecifiedrheumatoidarthritis,rightwristM06.832 Otherspecifiedrheumatoidarthritis,leftwristM06.839* Otherspecifiedrheumatoidarthritis,unspecifiedwristM06.841 Otherspecifiedrheumatoidarthritis,righthandM06.842 Otherspecifiedrheumatoidarthritis,lefthandM06.849* Otherspecifiedrheumatoidarthritis,unspecifiedhandM06.851 Otherspecifiedrheumatoidarthritis,righthipM06.852 Otherspecifiedrheumatoidarthritis,lefthipM06.859* Otherspecifiedrheumatoidarthritis,unspecifiedhipM06.861 Otherspecifiedrheumatoidarthritis,rightkneeM06.862 Otherspecifiedrheumatoidarthritis,leftkneeM06.869* Otherspecifiedrheumatoidarthritis,unspecifiedkneeM06.871 Otherspecifiedrheumatoidarthritis,rightankleandfootM06.872 Otherspecifiedrheumatoidarthritis,leftankleandfootM06.879* Otherspecifiedrheumatoidarthritis,unspecifiedankleandfootM06.88 Otherspecifiedrheumatoidarthritis,vertebraeM06.89 Otherspecifiedrheumatoidarthritis,multiplesitesM06.9* Rheumatoidarthritis,unspecified



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M66.211 Spontaneousruptureofextensortendons,rightshoulderM66.212 Spontaneousruptureofextensortendons,leftshoulderM66.219* Spontaneousruptureofextensortendons,unspecifiedshoulderM66.811 Spontaneousruptureofothertendons,rightshoulderM66.812 Spontaneousruptureofothertendons,leftshoulderM66.819* Spontaneousruptureofothertendons,unspecifiedshoulderM75.00* AdhesivecapsulitisofunspecifiedshoulderM75.01 AdhesivecapsulitisofrightshoulderM75.02 AdhesivecapsulitisofleftshoulderM75.100* Unspecifiedrotatorcufftearorruptureofunspecifiedshoulder,not specifiedastraumaticM75.101* Unspecifiedrotatorcufftearorruptureofrightshoulder,notspecified as traumaticM75.102* Unspecifiedrotatorcufftearorruptureofleftshoulder,notspecified as traumaticM75.110* Incompleterotatorcufftearorruptureofunspecifiedshoulder,not specifiedastraumaticM75.111 Incompleterotatorcufftearorruptureofrightshoulder,notspecified as traumaticM75.112 Incompleterotatorcufftearorruptureofleftshoulder,notspecified as traumaticM75.120* Completerotatorcufftearorruptureofunspecifiedshoulder,notspecified as traumaticM75.121 Completerotatorcufftearorruptureofrightshoulder,notspecified as traumaticM75.122 Completerotatorcufftearorruptureofleftshoulder,notspecified as traumaticM75.20* Bicipitaltendinitis,unspecifiedshoulderM75.21 Bicipitaltendinitis,rightshoulderM75.22 Bicipitaltendinitis,leftshoulderM75.30* CalcifictendinitisofunspecifiedshoulderM75.31 CalcifictendinitisofrightshoulderM75.32 CalcifictendinitisofleftshoulderM75.40* ImpingementsyndromeofunspecifiedshoulderM75.41 Impingementsyndromeofrightshoulder

Selected Shoulder Conditions (ICD-9-CM 726.0, 726.10 to 726.19 range, 726.2, 727.61)


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M75.42 ImpingementsyndromeofleftshoulderM75.50* BursitisofunspecifiedshoulderM75.51 BursitisofrightshoulderM75.52 BursitisofleftshoulderM75.80* Othershoulderlesions,unspecifiedshoulderM75.81 Othershoulderlesions,rightshoulderM75.82 Othershoulderlesions,leftshoulderM75.90* Shoulderlesion,unspecified,unspecifiedshoulderM75.91* Shoulderlesion,unspecified,rightshoulderM75.92* Shoulderlesion,unspecified,leftshoulder

M48.06 Spinalstenosis,lumbarregionM48.07 Spinalstenosis,lumbosacralregionM99.23 SubluxationstenosisofneuralcanaloflumbarregionM99.33 OsseousstenosisofneuralcanaloflumbarregionM99.43 ConnectivetissuestenosisofneuralcanaloflumbarregionM99.53 IntervertebraldiscstenosisofneuralcanaloflumbarregionM99.63 Osseousandsubluxationstenosisofintervertebralforaminaof lumbarregionM99.73 Connectivetissueanddiscstenosisofintervertebralforaminaof lumbarregion

Selected Shoulder Conditions (ICD-9-CM 726.0, 726.10 to 726.19 range, 726.2, 727.61) (continued)

Spinal Stenosis of the Lumbar Region (ICD-9-CM 724.02)



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S43.421A Sprainofrightrotatorcuffcapsule,initialencounterS43.421D Sprainofrightrotatorcuffcapsule,subsequentencounterS43.421S Sprainofrightrotatorcuffcapsule,sequelaS43.422A Sprainofleftrotatorcuffcapsule,initialencounterS43.422D Sprainofleftrotatorcuffcapsule,subsequentencounterS43.422S Sprainofleftrotatorcuffcapsule,sequelaS43.429A* Sprainofunspecifiedrotatorcuffcapsule,initialencounterS43.429D* Sprainofunspecifiedrotatorcuffcapsule,subsequentencounterS43.429S* Sprainofunspecifiedrotatorcuffcapsule,sequelaS83.501A* Sprainofunspecifiedcruciateligamentofrightknee,initialencounterS83.501D* Sprainofunspecifiedcruciateligamentofrightknee, subsequentencounterS83.501S* Sprainofunspecifiedcruciateligamentofrightknee,sequelaS83.502A* Sprainofunspecifiedcruciateligamentofleftknee,initialencounterS83.502D* Sprainofunspecifiedcruciateligamentofleftknee,subsequentencounterS83.502S* Sprainofunspecifiedcruciateligamentofleftknee,sequelaS83.509A* Sprainofunspecifiedcruciateligamentofunspecifiedknee, initial encounterS83.509D* Sprainofunspecifiedcruciateligamentofunspecifiedknee, subsequentencounterS83.509S* Sprainofunspecifiedcruciateligamentofunspecifiedknee,sequelaS83.511A Sprainofanteriorcruciateligamentofrightknee,initialencounterS83.511D Sprainofanteriorcruciateligamentofrightknee,subsequentencounterS83.511S Sprainofanteriorcruciateligamentofrightknee,sequelaS83.512A Sprainofanteriorcruciateligamentofleftknee,initialencounterS83.512D Sprainofanteriorcruciateligamentofleftknee,subsequentencounterS83.512S Sprainofanteriorcruciateligamentofleftknee,sequelaS83.519A* Sprainofanteriorcruciateligamentofunspecifiedknee,initialencounterS83.519D* Sprainofanteriorcruciateligamentofunspecifiedknee, subsequentencounterS83.519S* Sprainofanteriorcruciateligamentofunspecifiedknee,sequelaS83.521A Sprainofposteriorcruciateligamentofrightknee,initialencounterS83.521D Sprainofposteriorcruciateligamentofrightknee,subsequentencounter

Selected Sprains – Rotator Cuff, Cruciate Ligament, and Ankle (ICD-9-CM 840.4, 844.0, 844.1, 844.2, 844.8, 845.01, 845.00 to 845.09 range, 905.7, V58.89)


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S83.521S Sprainofposteriorcruciateligamentofrightknee,sequelaS83.522A Sprainofposteriorcruciateligamentofleftknee,initialencounterS83.522D Sprainofposteriorcruciateligamentofleftknee,subsequentencounterS83.522S Sprainofposteriorcruciateligamentofleftknee,sequelaS83.529A* Sprainofposteriorcruciateligamentofunspecifiedknee,initialencounterS83.529D* Sprainofposteriorcruciateligamentofunspecifiedknee, subsequentencounterS83.529S* Sprainofposteriorcruciateligamentofunspecifiedknee,sequelaS93.401A* Sprainofunspecifiedligamentofrightankle,initialencounterS93.401D* Sprainofunspecifiedligamentofrightankle,subsequentencounterS93.401S* Sprainofunspecifiedligamentofrightankle,sequelaS93.402A* Sprainofunspecifiedligamentofleftankle,initialencounterS93.402D* Sprainofunspecifiedligamentofleftankle,subsequentencounterS93.402S* Sprainofunspecifiedligamentofleftankle,sequelaS93.409A* Sprainofunspecifiedligamentofunspecifiedankle,initialencounterS93.409D* Sprainofunspecifiedligamentofunspecifiedankle, subsequentencounterS93.409S* Sprainofunspecifiedligamentofunspecifiedankle,sequelaS93.411A Sprainofcalcaneofibularligamentofrightankle,initialencounterS93.411D Sprainofcalcaneofibularligamentofrightankle,subsequentencounterS93.411S Sprainofcalcaneofibularligamentofrightankle,sequelaS93.412A Sprainofcalcaneofibularligamentofleftankle,initialencounterS93.412D Sprainofcalcaneofibularligamentofleftankle,subsequentencounterS93.412S Sprainofcalcaneofibularligamentofleftankle,sequelaS93.419A* Sprainofcalcaneofibularligamentofunspecifiedankle,initialencounterS93.419D* Sprainofcalcaneofibularligamentofunspecifiedankle, subsequentencounterS93.419S* Sprainofcalcaneofibularligamentofunspecifiedankle,sequelaS93.421A Sprainofdeltoidligamentofrightankle,initialencounterS93.421D Sprainofdeltoidligamentofrightankle,subsequentencounterS93.421S Sprainofdeltoidligamentofrightankle,sequelaS93.422A Sprainofdeltoidligamentofleftankle,initialencounterS93.422D Sprainofdeltoidligamentofleftankle,subsequentencounter

Selected Sprains – Rotator Cuff, Cruciate Ligament, and Ankle (ICD-9-CM 840.4, 844.0, 844.1, 844.2, 844.8, 845.01, 845.00 to 845.09 range, 905.7, V58.89) (continued)


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S93.422S Sprainofdeltoidligamentofleftankle,sequelaS93.429A* Sprainofdeltoidligamentofunspecifiedankle,initialencounterS93.429D* Sprainofdeltoidligamentofunspecifiedankle,subsequentencounterS93.429S* Sprainofdeltoidligamentofunspecifiedankle,sequelaS93.431A Sprainoftibiofibularligamentofrightankle,initialencounterS93.431D Sprainoftibiofibularligamentofrightankle,subsequentencounterS93.431S Sprainoftibiofibularligamentofrightankle,sequelaS93.432A Sprainoftibiofibularligamentofleftankle,initialencounterS93.432D Sprainoftibiofibularligamentofleftankle,subsequentencounterS93.432S Sprainoftibiofibularligamentofleftankle,sequelaS93.439A* Sprainoftibiofibularligamentofunspecifiedankle,initialencounterS93.439D* Sprainoftibiofibularligamentofunspecifiedankle,subsequentencounterS93.439S* Sprainoftibiofibularligamentofunspecifiedankle,sequelaS93.491A Sprainofotherligamentofrightankle,initialencounterS93.491D Sprainofotherligamentofrightankle,subsequentencounterS93.491S Sprainofotherligamentofrightankle,sequelaS93.492A Sprainofotherligamentofleftankle,initialencounterS93.492D Sprainofotherligamentofleftankle,subsequentencounterS93.492S Sprainofotherligamentofleftankle,sequelaS93.499A* Sprainofotherligamentofunspecifiedankle,initialencounterS93.499D* Sprainofotherligamentofunspecifiedankle,subsequentencounterS93.499S* Sprainofotherligamentofunspecifiedankle,sequela

Selected Sprains – Rotator Cuff, Cruciate Ligament, and Ankle (ICD-9-CM 840.4, 844.0, 844.1, 844.2, 844.8, 845.01, 845.00 to 845.09 range, 905.7, V58.89)(continued)


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M51.04 Intervertebraldiscdisorderswithmyelopathy,thoracicregionM51.05 Intervertebraldiscdisorderswithmyelopathy,thoracolumbarregionM51.06 Intervertebraldiscdisorderswithmyelopathy,lumbarregionM51.07 Intervertebraldiscdisorderswithmyelopathy,lumbosacralregionM51.14 Intervertebraldiscdisorderswithradiculopathy,thoracicregionM51.15 Intervertebraldiscdisorderswithradiculopathy,thoracolumbarregionM51.16 Intervertebraldiscdisorderswithradiculopathy,lumbarregionM51.17 Intervertebraldiscdisorderswithradiculopathy,lumbosacralregionM51.24 Otherintervertebraldiscdisplacement,thoracicregionM51.25 Otherintervertebraldiscdisplacement,thoracolumbarregionM51.26 Otherintervertebraldiscdisplacement,lumbarregionM51.27 Otherintervertebraldiscdisplacement,lumbosacralregionM51.34 Otherintervertebraldiscdegeneration,thoracicregionM51.35 Otherintervertebraldiscdegeneration,thoracolumbarregionM51.36 Otherintervertebraldiscdegeneration,lumbarregionM51.37 Otherintervertebraldiscdegeneration,lumbosacralregionM51.44 Schmorl’snodes,thoracicregionM51.45 Schmorl’snodes,thoracolumbarregionM51.46 Schmorl’snodes,lumbarregionM51.47 Schmorl’snodes,lumbosacralregionM51.84 Otherintervertebraldiscdisorders,thoracicregionM51.85 Otherintervertebraldiscdisorders,thoracolumbarregionM51.86 Otherintervertebraldiscdisorders,lumbarregionM51.87 Otherintervertebraldiscdisorders,lumbosacralregionM51.9* Unspecifiedthoracic,thoracolumbarandlumbosacral intervertebraldiscdisorder

Thoracic, Thoracolumbar, and Lumbosacral Intervertebral Disc Disorders (ICD-9-CM 722.10, 722.11, 722.31, 722.32, 722.51, 722.52, 722.72, 722.73, 722.90, 722.92, 722.93, 724.4)


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SpecifyinganatomicallocationandlateralityrequiredbyICD-10iseasierthanyouthink.Thisdetailreflectshowphysiciansandclinicianscommunicateandtowhattheypayattention-itisamatterofensuringtheinformationiscapturedinyourdocumentation.

InICD-10-CM,therearethreemaincategoriesofchanges:

Definition Changes

Terminology Differences

Increased Specificity

Fororthopedicsthefocusisonincreasedspecificity.Over1/3oftheexpansionofICD-10codesisduetotheadditionoflaterality(left,right,orbilateral).Physiciansandotherclinicianslikelyalreadynotelateralitywhenevaluatingtheclinicallypertinentanatomicalsite(s).



M21.722 Unequallimblength(acquired),lefthumerusM25.561 PaininrightkneeM25.562 PaininleftkneeS72.344A Nondisplacedspiralfractureofshaftofrightfemur,initialencounterfor closedfracture

ICD-10 Code Examples

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FRACTURES

Increased SpecificityWhendocumentingfractures,includethefollowingparameters:

1. Type e.g.Open,closed,pathological,neoplasticdisease,stress

2. Pattern e.g.Comminuted,oblique,segmental,spiral,transverse

3. Etiologytodocumentintheexternalcausecodes

4. Encounterofcare e.g.Initial,subsequent,sequelae

5. Healingstatus,ifsubsequentencounter e.g.Normalhealing,delayedhealing,nonunion,malunion

6. Localization e.g.Shaft,head,neck,distal,proximal,styloid

7. Displacement e.g.Displaced,nondisplaced

8. Classification e.g.Gustilo-Anderson,Salter-Harris

9. Anycomplications,whetheracuteordelayed e.g.Directresultoftraumasustained

Inaddition,dependingonthecircumstances,itmaybenecessarytodocumentintra-articularorextra-articularinvolvement.Forcertainconditions,thebonemaybeaffectedattheproximalordistalend.Thoughtheportionoftheboneaffectedmaybeatthejointateitherend,thesitedesignationwillbethebone,notthejoint.

S52.521A Torusfractureoflowerendofrightradius,initialencounter forclosedfractureS52.521D Torusfractureoflowerendofrightradius,subsequentencounterfor fracturewithroutinehealingS42.021K Displacedfractureoftheshaftofrightclavicle,subsequentforfracture with nonunion


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ARTHRITIS

Increased SpecificityInICD-10-CM,therearespecificcodesforprimaryandsecondaryarthritis.Withinthesecondaryarthritiscodestherearespecificcodesforpost-traumaticosteoarthritisandothersecondaryosteoarthritis.Forsecondaryosteoarthritisofthehipthereisalsoacodefordysplasticosteoarthritis.

ArthritiscodesinICD-10-CMisbothsimilaranddifferentthanICD-9-CM.Forexample,currently,inICD-9,osteoarthritiscanbedescribedasdegenerative,hypertrophic,orsecondarytootherfactors,andthetypeasgeneralizedorlocalized.ICD-10providesmoreoptionsforthecodingosteoarthritisrelatedencounters,including:

• Generalizedformsofosteoarthritisorarthritiswheremultiplejointsareinvolved.

• Localizedformsofosteoarthritiswithmorespecificitythatincludesprimaryversussecondarytypes,subtypes,laterality,andjointinvolvement.

Indicatethetype,location,andspecificbonesandjoints(multiplesitesifapplicable)involvedinthedisease.Inaddition,describeanyrelatedunderlyingdiseasesorconditions.

M19.041 PrimaryosteoarthritisrighthandM19.241 Secondaryosteoarthritis,righthandM05.432 Rheumatoidmyopathywithrheumatoidarthritisofleftwrist


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INJURIES

Increased SpecificityICD-9usedseparate“Ecodes”torecordexternalcausesofinjury.ICD-10betterincorporatesthesecodesandexpandssectionsonpoisoningsandtoxins.

Whendocumentinginjuries,includethefollowing:

1. EpisodeofCare e.g.Initial,subsequent,sequelae

2. Injurysite Beasspecificaspossible

3. Etiology Howwastheinjurysustained(e.g.sports,motorvehiclecrash,pedestrian,slipandfall, environmentalexposure,etc.)?

4. PlaceofOccurrence e.g.School,work,etc.

Initialencountersmayalsorequire,whereappropriate:

1. Intent e.g.Unintentionaloraccidental,self-harm,etc.

2. Status e.g.Civilian,military,etc.

Example1:Aleftkneestraininjurythatoccurredonaprivaterecreationalplaygroundwhenachildlandedincorrectlyfromatrampoline:• Injury: S86.812A,Strainofothermuscle(s)andtendon(s)atlower

leglevel,leftleg,initialencounter• Externalcause: W09.8xxA,Fallonorfromotherplaygroundequipment,

initial encounter• Placeofoccurrence: Y92.838,Otherrecreationareaastheplaceofoccurrence

oftheexternalcause• Activity: Y93.44,Activitiesinvolvingrhythmicmovement,

trampolinejumpingExample2:OnOctober31st,KellywasseenintheERforshoulderpainandX-raysindicatedtherewasafractureoftherightclavicle,shaft.Shereturnedthreemonthslaterwithcomplaintsofcontinuingpain.X-raysindicatedanonunion.ThesecondencounterfortherightclaviclefractureiscodedasS42.021K, Displaced fracture of the shaft of right clavicle, subsequent for fracture with nonunion.


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Qualityclinicaldocumentationisessentialforcommunicatingtheintentofanencounter,confirmingmedicalnecessity,andprovidingdetailtosupportICD-10codeselection.Insupportofthisobjective,wehaveprovidedoutpatientfocusedscenariostoillustratespecificICD-10documentationandcodingnuancesrelatedtoyourspecialty.

ThefollowingscenarioswerenativelycodedinICD-10-CMandICD-9-CM.Aspatienthistoryandcircumstanceswillvary,thesebriefscenariosareillustrativeinnatureandshouldnotbestrictlyinterpretedorusedasdocumentationandcodingguidelines.Eachscenarioisselectivelycodedtohighlightspecifictopics;therefore,onlyasubsetoftherelevantcodesarepresented.

Clinical Scenarios


Scenario Details

Chief Complaint•Firstfollow-upvisitpostfracturetoleftfemur.

History• 85 year old retired male sustained a crush injury to his left femur from a forklift accident while

he was a consumer in a building store1.Theforklifthithisleftlegandcrushedit.• Patient sustained an open, displaced, transverse fracture of his left middle femur shaft.

There was a 2-3 cm skin avulsion and moderate surrounding tissue damage to his left lateral thigh approximately five inches above the knee. Gustilo Class II fracture2.

•S/PORIFofleftfemurtwoweekspriortotoday’svisit.Receivedtetanusvaccine while in hospital.

•PatienthasbeenreceivingdailyPTathomesinceheleftthehospitaloneweekago.Patientisnon-weightbearingontheLLE.

Exam•X-raytodayofleftfemurcomparedtosurgicalfilmsshowgoodhealing.Allsurgicalplatesand

screws intact. No signs of infection at the surgical site3.•Patientreportsthatpainisdecreasingdaily.Abletobendleftknee45º,withfullROMtoleftankleandtoes.Mildpedaledemanoted.Circulationtoleftfootisexcellentwithpalpablepedalpulsesandbriskcapillaryrefill<2sec.

•PhysicaltherapyreportspatientisprogressingwellandiscompliantwithROMinstructions.GaitsteadywithLLEinhingedkneebraceandcrutches.

Scenario 1: Fracture Follow-Up Visit

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Assessment and Plan•Leftfemurfractureishealingappropriately.•DiscontinuehomePT.PatienttobegindailyrehabatPTCentertomorrow.ContinuetoincreasePTexercises.UpdatedorderssenttoPTofficeanddiscussedwithpatient.

•Seepatientinofficein4weeksforrepeatfilms,evaluationofsurgicalsiteandPTprogression.

SummaryofICD-10-CMImpactsClinical Documentation

1.Describescircumstancesofinjury.WithICD-10-CM,youmustre-documentorreferenceextensivedetailssurroundingthecircumstancesofinjurytoensurecorrectcodingandproperclaimsprocessing.Thisincludestimeframe,etiology,episodeofcare,injurysite,cause,andplaceofoccurrence.AccordingtotheICD-10-CMguidelines,placeofoccurrence,activityandworkstatuscodesareonlycodedonthefirstvisit.Assigntheexternalcausecode,withtheappropriate7thcharacter(initialencounter,subsequentencounterorsequelae)foreachencounterforwhichtheinjuryorconditionisbeingtreated.Asthisisasubsequentencounter,thisinformationisreflectedinthe7thcharacteroftheICD-10-CMcode(e.g.,V83.7xxDforV83.7xxD,Persononoutsideofspecialindustrialvehicleinjuredinnontrafficaccident).

NotethatpertheguidelinesthereisnonationalrequirementformandatoryICD-10-CMexternalcausecodereporting.Youmayberequiredtoreportthembasedonastatebasedexternalcausecodemandate(forexample,foratraumaregistry)orasrequiredbyaparticularpayor.Providersareencouragedtovoluntarilyreportexternalcausecodes,astheyprovidevaluabledataforinjuryresearchandmayassistinclaimsprocessing/insurancecoordinationofbenefits.

2.Describesthefracture/injury–WithICD-10-CM,youneedtodocumentspecificsaboutthetypeoffractureinjurytoensurecorrectcoding.Includeinformationontheside,location(makereferencetotheappropriateanatomicallandmarks)andclassification.Thefracturedescriptionaboveiswelldefinedandincludesdescriptionthatsupportsthenecessaryitemssuchastraumatic,open,displaced,middleoffemurshaft,subsequentencounter,routinehealing,andfractureclassificationGustiloclassII.Thisinformationisreflectedinthe7thcharacteroftheICD-10-CMcode(e.g.,S72.322E)

3.Notethepresenceofinfection(ifany).Documentingwhethertherearesignsofinfectionwillsupportifadditionalsurgicalinterventionisnecessaryandifadditionaladversesequelaedevelop.

Scenario 1: Fracture Follow-Up Visit (continued)

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Other Impacts•Correctlycodingthefractureensurestheproviderwillbereimbursedforappropriatefollow-upvisitsandthatthepatientcanreceiveappropriateoutpatient(i.e.PT,imaging,etc.)services.Uncomplicatedfollow-upvisitsmaybebundledbyapayor.

•Thecircumstancesofinjurysuchaswhereandhowitoccurredareimportantforclaimsprocessingandcoordinationofbenefits.

Coding

Scenario 1: Fracture Follow-Up Visit (continued)

ICD-9-CM Diagnosis Codes

821.11 Openfractureofshaftoffemur

E919.2 Accidentscausedbylifting machines and appliances

N/A


S72.322E Displacedtransversefractureof shaftofleftfemur,subsequent encounterforopenfracturetypeIorII withroutinehealingW23.0xxD Caught,crushed,jammed,orpinched betweenmovingobjectssubsequent encounterV83.7xxD Persononoutsideofspecialindustrial vehicleinjuredinnontrafficaccident

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Scenario Details

Chief Complaint•“Frozen”rightshoulder1

History•52yearoldfemalewithrightshoulderpain;“6”on1-10scale.Seeninmyofficetwoweeksagoforsamec/o;prolongedsymptomsafteroralnon-steroidalchallenge.Decreased ROM noted. Difficulty with daily activities including carrying briefcase, driving, dressing and cooking noted. Patient states sleep is also being affected2.

•TakesNSAIDtwicedailyforpain.Patientreportsthemedication“helpssome.”Exam

•Rightshoulderfilmnegative.Tendernessnoted.•Activeandpassiverangeofmotionremaintorightshoulderissignificantlydecreased.•Neurologicalexamnormal.

Assessment and Plan•Adhesivecapsulitisofrightshoulder.•Administeredsubacromialcorticosteroidinjection,rightshoulder.• Pain control discussed. Patient declines Rx oral corticosteroid medications. Recommended to continuewithNSAID,discussedsideeffects.

•PTtherapyforROMofshoulder•Scheduledafollow-upvisitin2weeks.


1.ICD-10-CMcannowcapturethesideandspecificboneorjoint.Includingthespecificinformationensuresthecorrect“side”codeisassigned.

2.Beasspecificaspossiblewhendescribingtheeffectsofthecondition.Coding

Scenario 2: Shoulder ROM Office Visit


726.0 Adhesivecapsulitisofshoulder


M75.01 Adhesivecapsulitisofrightshoulder

Other Impacts

Identifyingtheaffectedsideisimportant,assomepayerswillnotreimburseclaimswith“unspecified”codes.

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Scenario Details

Chief Complaint•Instabilityofrightknee.

History•This29yearoldsinglemale,newpatient,presentstodayforevaluationofaninjurytohisrightknee.Patientstatesheinitiallyinjuredhisrightkneeoneyearagoplayinghockeyandthenreinjuredthesamekneethreeweeksagoplayingsoftball.

•Hedescribesthepainas6/10,withthrobbingintermittently;paindoesnotinterferewithsleep.Hestatesthesymptomsaremadeworsewithexercise,squatting,kneeling,andcertaintwistingmotions.Lockingandclickingpresent.Symptomsseemtoimprovewithrestandnophysicalactivity.

•MRIfromoneyearagoshowspartialrightanteriorcruciateligamenttear.•MRIfilmsfollowinganERvisitthreeweeksagoshowatearoftherightmedialmeniscus.•Treatmenthasconsistedofbracingandexercise.Hehashadnophysicaltherapy,noinjections,and

has never used a cane or a crutch.•Hecomplainsofinstabilityofhisrightknee,especiallywithdirectionalchangeandspecificallywithpivoting.

•Nohistoryofrheumatoidarthritisorosteoarthritis.•13pointreviewofsystemsnegative;pastmedicalhistorynoncontributory.

Exam•Vitalsigns:BP:110/65HR:61R:20T:98.6Ht:6.0Wt:201lbs.•Slightantalgicgaitobserved.•Nogrossdeformitiesofthelowerextremities,rangeofmotionofthebothkneesiswithinnormallimits.Palpablepatellofemoralcrepitationwithmoderatepositivepatellarsqueezetest.

•Obviousgrade2to3+Lachmanexamwithpoorendpointandgrosslypositiveshift.•Painpresentwithpalpationtothemidportionofthemedialjointline;aggravatedbyApley

compression test and McMurray maneuver.• Effusion palpable.•Posteriorcruciateligamentandcollateralligamentsappearintact.•Neurovascularexamintactbilaterally.•Remainderofphysicalexaminationwithinnormallimits.

Assessment and Plan•Medialmeniscustearofrightknee;symptomaticwithpainandinstability.•Functionalinstabilityduetoanteriorcruciateligamentinsufficiency.•Willtreatconservativelyfornow.

Scenario 3: Tear of Medial Meniscus With Anterior Cruciate Ligament Injury

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1.InICD-10-CM,olddisruptionsofanyofthefourkneeligamentsmaptochronicinstabilityoftheknee.FollowingcodingguidelinesinbothICD-9andICD-10,theolddisruptionandchronicinstabilityarenotreportedinadditiontothecurrentinjury.

2.Painmaybeconsideredintegraltotheunderlyingmedicalconditionofthemedialmeniscustear,and thus is not coded separately as a symptom.

3.Inthisexample,themedialmeniscusteariscodedwithunspecifiedastheinformationinthemedicalrecordisinsufficienttoassignamorespecificcode(e.g.,buckethandle,peripheral).“Other”[forms]wouldbeusedwhentheinformationinthemedicalrecordprovidesdetailforwhichaspecificcodedoesnotexist.

Coding

Other Impacts

S83.2Ø6hasa7thcharacterbasedoninitialencounter,subsequentencounter,orsequela.

Thisinjurycodewillcontinuetobecodeduntiltheconditionistotallyresolvedwithoutanysequela.Whenthepatientreturnsforfollowupthe7thcharacterchanges.

The7thcharacterdefinitionsforthiscategoryare:

• A – Initial encounter for injuryExamplesofactivetreatmentare:•surgicaltreatment, •emergencydepartmentencounter,and •evaluationandtreatmentbyanewphysician.

• D – Subsequent encounter for injury with routine healing Examplesofsubsequentencounterisusedforencountersafterthepatienthasreceivedactivetreatmentoftheconditionandisreceivingroutinecarefortheconditionduringthehealingorrecoveryphase.Examplesofsubsequentcareare: •castchangeorremoval, •removalofexternalorinternalfixationdevice, •medicationadjustment, •otheraftercareandfollowupvisitsfollowingtreatmentoftheinjuryorcondition.

• S – Sequela“S”isforuseforcomplicationsorconditionsthatariseasadirectresultofacondition.Whenusing7thcharacter“S”,itisnecessarytouseboththeinjurycodethatprecipitatedthesequelaandthecodeforthesequelaitself.The“S”isaddedonlytotheinjurycode,notthesequelacode.The7thcharacter“S”identifiestheinjuryresponsibleforthesequela.Thespecifictypeofsequela(e.g.contractureafterfracture)issequencedfirst,followedbytheinjurycode.

Scenario 3: Tear of Medial Meniscus With Anterior Cruciate Ligament Injury (continued)


836.0 Tearofmedialcartilageormeniscus ofknee,current 719.06 Effusion,knee


S83.2Ø6A Unspecifiedtearofunspecified meniscus,currentinjury,rightknee, initial encounterM25.461 Effusion,knee,right

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Scenario Details

Chief Complaint•“MyneckhurtsandIhaveatinglingpainsensationgoingdownmyrightarm.”

History•Patientisa68year-oldmalewithhistoryofneckpainthathasbeenworseningoverthelasttwoyears.Recently,hehasexperiencedsomenumbnessandapainfultinglingsensationinhisrightarmgoingdowntohisthumb.Noothersymptomsorpertinentmedicalhistory.

Review of Systems, Physical Exam, Laboratory Tests•Reviewofsystemsisnegativeexceptfortheneckpainandsensationsinhisrightarmdescribedabove.Nohistoryofacuteinjurytoneckorarm.

•Physicalexamisnormalexceptforneurologicalexamoftherightupperextremity,whichrevealsslightdecreasetosensationinthethumbandforefingerregionofthehandintheC6nerverootdistribution.Noevidenceofweaknessinthemusclesofthearmorhand.

•MRIscanoftheneckshowsdegenerativechangesoftheC5-6discwithlateralprotrusionofdiscmaterial.Nootherabnormalitiesnoted.

Assessment and Plan•CervicaltransforaminalinjectionatC5-6


•SubcategoryM50.1describescervicaldiscdisorders.M50.12Cervicaldiscdiseasethatincludesdegenerationofthediscasacombinationcode.The5thcharacterdifferentiatesvariousregionsofthecervicalspine(highcervicalC2-3andC3-4;mid-cervicalC4-5,C5-6,andC6-7;cervicothoracicC7-T1andtheassociatedradiculopathiesateachlevel).Thisisacombinationcodethatincludesthediscdegenerationandradiculopathy

Coding

Scenario: Cervical Disc Disease


722.0 Cervical disc displacement without myelopathy722.4 Degenerationofcervical intervertebraldisc


M50.12 Cervical disc disorder with radiculopathy,mid-cervicalregion

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Scenario Details

Chief Complaint• “Iwascrossingthestreetandgothitbyacar.Myrightlegisbrokenandmyleftwristhurts.”

History•Patientisa24-year-oldmalebroughttotheEmergencyDepartmentafterbeingstruckbyacarwhilecrossingthestreet.Hedeniesanypreviousmedicaldiseasesorsurgicalprocedures.

Review of Systems, Physical Exam, Laboratory TestsVSSandPhysicalExamarewithinnormallimitswiththefollowingexceptions:

•RLE:openfractureofthemid-shaftregionofthefemur.Woundisapproximately15cminlengthandthebonefragmentsshowinjurytoboneandperiosteum(GustiloTypeIIIB);atleastthreefragmentsarevisible.Noapparentnerveorvascularinjuriesarenoted.

•LUE:skinintactoverentireextremity.Thereisobviousdeformityofthewrist,whichispainfultopalpation.Neurologicalandvascularexamofthehandisintact.

•X-rays:comminutedmid-shaftfractureoftherightfemur.Thereisatransversefractureofthedistalleftradiusjustproximaltothewristjointwithdorsaldisplacementofthedistalfragment(Colles’fracture).Allotherx-raysarenormal.

Hospital Course•Thepatientwasadmittedtothehospitalandtakendirectlytotheoperatingroomforinitialtreatment,includingdebridementandirrigationoftherightopenfractureandsplintingoftheleftwrist.Onthesecondhospitalday,thepatientwasagaintakentotheoperatingroomfordefinitivetreatmentofthebothfracturesbyopenreductionandinternalfixation(ORIF)techniques.

Assessment and Plan•Opencomminutedfractureoftherightfemur,mid-shafttreatedbyORIF•ClosedtransversefractureofthedistalleftradiustreatedbyORIF•Injuriescausedbyvehicle-pedestrianaccident


•Whenoneormorefracturesoccuranddifferentsurgicalproceduresareperformed,allofthefirstproceduresarecodedasinitialencounter.The7thcharacterisnotinfluencedbytheorderofthesurgicalprocedures.

•Whenmultiplesurgicalproceduresareperformed,althoughthecodesforeachinjuryaredifferent,thereasonisthesame.Inthiscase,thefractureofthefemurandwristwerebothcausedbybeinghitbyacar.

•Surgicaltreatmentisconsidered“active”treatmentorinitialtreatmentevenifitisnotthefirstsurgicalprocedurefortheinjurybeingtreated.

•OpenfracturesareclassifiedbytheirGustillotypewith7thcharactersspecifictotypeI,II,IIIA,IIIB or IIIC.

•ThedefinitionsofinitialandsubsequentarefoundinVolume2guidelinesunderChapter19.

Scenario: Struck by Car

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7thcharacter“A”,initialencounterisusedwhilethepatientisreceivingactivetreatmentforthecondition.Examples of active treatment are:surgicaltreatment,emergencydepartmentencounter,andevaluationandcontinuingtreatmentbythesameoradifferentphysician.

7thcharacter“D”subsequentencounterisusedforencountersafterthepatienthasreceivedactivetreatmentoftheconditionandisreceivingroutinecarefortheconditionduringthehealingorrecoveryphase.Examples of subsequent care are:castchangeorremoval,anx-raytocheckhealingstatusoffracture,removalofexternalorinternalfixationdevice,medicationadjustment,otheraftercareandfollowupvisitsfollowingtreatmentoftheinjuryorcondition.

•TheICD-10codeV03.10xAillustratestheuseofplaceholder“x”whena7thcharacterisrequired,butthecodeonlyprogressestoa5thcharacterlevel.Inthisexamplethenthe“x”placeholderisputintocharacterspaceposition6andthenthe7thcharacterforepisodeisaddedlast.

In the chart you can see the possibilities of coding future encounters for this injury:

Scenario: Struck by Car (continued)

Injury Code

S72.351CFracture,comminutedshaftoffemur,initial encounterfortreatmentofopen fracture type IIIB

S72.351FFracture,comminutedshaftoffemur,subsequentencounterfortreatmentofopenfracturetypeIIIBwith routine healing

S72.351NFracture,comminutedshaftoffemur,subsequentencounterfortreatmentofopenfracturetypeIIIBwithnonunion

External Cause Code

V03.10xAPedestrian,onfoot,injuredincollisionwithcar,pick-uptruck,orvanintrafficaccident,initial encounter

V03.10xDPedestrian,onfoot,injuredincollisionwithcar,pick-uptruck,orvanintrafficaccident,subsequent encounter

V03.10xSPedestrian,onfoot,injuredincollisionwithcar,pick-uptruck,orvanintrafficaccident,sequela

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• Report the external cause codes in ICD-10-CM. Includewhendocumented:

•Theexternalcauseforthecodes•Whatthepersonwasdoingwhentheywereinjured(whendocumented)•Locationoftheaccident(whendocumented)•Thestatusofthepatientsuchasstudent,volunteer,atwork,andetc.(whendocumented)

The “how it happened” external cause code should never be a first-listed code on a claim. Thiscodeshouldbeusedonalladditionalclaimsforthisinjuryfollowingthesameguidelineforthe7thcharacterwiththesamedefinitionofinitialversussubsequentorsequela.

Coding

Scenario: Struck by Car (continued)


821.11 Fracture,openshaftoffemur

813.41 Fracture, Colles’

E18.7 Accident,Motorvehicleinvolving collision with pedestrian injuringpedestrianE849.5 Accident,occurringinstreet


S72.351C Fracture,comminutedshaftoffemur, initialencounterfortreatmentofopen fracturetypeIIIBS52.532A Colles’fractureofleftradius,initial encounterforclosedfractureV03.10xA Pedestrian,onfoot,injuredincollision withcar,pick-uptruck,orvanintraffic accident, initial encounterY92.410 Unspecifiedstreetandhighway astheplaceofoccurrenceofthe external cause

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Scenario Details

Chief Complaint•“Ifellandhurtmyrighthip.”

History•Patientisa74-year-oldmalewhotrippedoverarugathome,fellandhadimmediatepaininhisrighthip.HewastransportedtotheEmergencyDepartmentbyambulance.Inadditiontohishippain,hehasahistoryofhighbloodpressurecurrentlytreatedwithZaroxolynandLisonopril.HeadmitsthathehasbeeninthehabitofcuttinghisBPpillsinhalftosavemoneyonrefills.Healsohasahistoryofamyocardialinfarctionseveralyearsagowithoutanycurrentmanifestations.

Review of Systems, Physical Exam, Laboratory Tests•Patientdeniesanysymptomsotherthanhippain;specificallydeniesanyrecenthistoryofchestpain,armpain,epigastricpainorshortnessofbreath

•BPonadmissiontotheED:180/95•X-ray:Rightintertrochanterichipfracture;noevidenceofotherbonyinjury•EKG:evidenceofoldmyocardialinfarction;noevidenceofrecentmyocardialinjury

Treatment in ED•PatientgivenIVmedicationsforpain(morphine1-2mgIVtitratedforrelief)•BPafterIVmedication:165/90

Assessment and Plan• Admit to hospital•NSIVat75cc/hour•Painmedications:morphine1-2mgIVprn•NPOforsurgery•Orthopedicsurgeryandanesthesiaconsults

SummaryofICD-10-CMImpacts Clinical Documentation

•Codingfracturesasspecificallyaspossiblecodetolocation,leftversusright,anddisplacedornon-displaced,openorclosed(7thcharacter)andinitial,subsequent,orsequela(7thcharacter)

•NOTEthatforS72codesthereare16differentlettersforthe7thcharacter.Notonlyaretheydividedbytypeofencounter,butalsoopenorclosed,healing,non-unionandtypeofopenorclosedfracture.Therefore,subsequentencountersmaybeanyofthefollowingcodesforaclosedfracture:

•S72.141G(Closed,delayedhealing)•S72.141K(Closed,non-union)•S72.141P(Closedmal-union)

Scenario: Fracture

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Scenario: Fracture (continued)

•CodingthemechanismofinjuryandplacewheretheinjuryoccurredfromIndexofExternalCausesthatisfoundinVolume3.Inthisindexthekeywordis“Fall”ishowtheaccidenthappened.Theseaccidentcodeswillalwayshavea7thcharacterthatreferstoaninitial,subsequent,orsequelaencounter.

•Thisaccidentcodewillalignwiththeactualinjurycodeuntilresolved.The7thcharacterwilltheninsubsequentencounterschangeto“subsequent”or“sequela”dependingonthedocumentationinsubsequentencounters.The“howithappened”externalcausecodeshouldneverbeafirst-listedcodeonaclaimperICD-10-CMcodingguidelines.

Example:

Injury Code

S72.141ADisplacedfracture,rightfemur,initial encounter

S72.141DDisplacedfracture,rightfemur,subsequent encounter

S72.141SDisplacedfracture,rightfemur,sequela encounter

External Cause Code

W18.09xAStrikingagainstotherobjectwithsubsequentfall,initial encounter

W18.09xDStrikingagainstotherobjectwithsubsequentfall,subsequent encounter

W18.09xSStrikingagainstotherobjectwithsubsequentfall,sequela encounter

Fracture Code for Subsequent Encounters

S72.141GDisplacedfracture,rightfemur,closedfracturedelayed healing

S72.141KDisplacedfracture,rightfemur,closedfracturewithnonunion

S72.141PDisplacedfracture,rightfemur,closedfracturewithmalunion

External Cause Code

W18.09xDStrikingagainstotherobjectwithsubsequentfall,subsequent encounter



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•ThecodeW18.09xDshouldbeusedonalladditionalclaimsforthisinjuryfollowingthesameguidelineforthe7thcharacterwiththesamedefinitionofinitialversussubsequentorsequela.

• Additional external cause codes should be used when documented for:•Whatthepersonwasdoingwhentheywereinjured(whendocumented)•Locationoftheaccident(whendocumented)•Thestatusofthepatientsuchasstudent,volunteer,atwork,andetc.(whendocumented)

•Codingrelevantco-morbidconditionssuchaspatient’sHTN•Codingmedicationnon-compliance(underdosing)fromtheTableofDrugs&ChemicalsfoundinVolume3.GototheTableandalongthelefthandsidelocatedthedrugnameandifdrugnameisnotfoundthensearchforthedrugclass.Thenmoveacrossthecolumnsto“underdosing”column.MovetotheTabularList(Volume1)forthe7thcharacterforinitial,subsequentorsequela.The7th character is foundatthebeginningofthecategoryT46andT50.

•Eachmedicationthatwasunder-dosedshouldbecodedseparatelyinICD-10-CM.•UseadjunctZcodeforintentionalunderdosingaftertheunderdosingasitisincludedinthedocumentation.TheinstructionfortheuseoftheseZcodesarefoundintheTabularList(Volume1)atthebeginningofthepoisoning,adverseeffectandunderdosingsectionabovecodeT36.

•Seethesnapshotphotoofthisinstructionbelownextto“Use additionalcode(s)tospecify”


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Coding

Other ImpactsICD-10hasunder-dosingcodewitheachdrugcodedseparatelywhileICD-0-CMdoesnothaveunderdosingcodes.


820.21 Femurfracture,closed, intertrochanteric section

E885.9 Fallfromotherslipping,tripping orstumblingE849.0 Accidentoccurringathome

401.9 Essential hypertension, unspecified412 OldmyocardialinfarctionNocodeavailable

Nocodeavailable

V15.81 Historyofnon-compliance with treatment


S72.141A Displacedintertrochantericfractureof therightfemur,initialencounterfor aclosedfracture(Note:fracturesnot indicated as displaced or non- displacedarecodedasdisplaced; fracturesnotindicatedasopenor closedarecodedasclosed)(Seenote belowS72categoryintheTabularList ofICD-10-CM)W18.09xA Strikingagainstotherobjectwith subsequentfall,initialencounterY92.009 Unspecifiedplaceinunspecified non-institutional(private)residenceas theplaceofoccurrenceoftheexternalcauseI10 Hypertension

I25.2 OldmyocardialinfarctionT46.4x6A Underdosingofangiotensin-converting- enzymeinhibitors,initialencounterT50.2x6A Underdosingofcarbonic-anhydrase inhibitors,benzothiadiazidesandother diuretics, initial encounterZ91.120 Intentionalunderdosingofmedication regimenduetofinancialhardship


Documents

ICD-10: Clinical Concepts for Orthopedics