ICD 10 CM IMPLEMENTATION DATE OCT 1, 2015 - Inova · ICD‐10‐CM IMPLEMENTATION DATE OCT 1, 2015 2. ... M40‐M43 Deforming dorsopathies (e.g., kyphosis, scoliosis, spondylolysis,

2015 Web_Non‐Traumatic Spine ICD10 (TR) 062415v2 1

Presented by:

Teri Romano, RN, MBA, CPC, CMDP

Source: http://journal.ahima.org/2015/02/04/us‐house‐committee‐to‐hold‐hearing‐on‐icd‐10‐implementation/

ICD‐10‐CM IMPLEMENTATION DATE

OCT 1, 2015

2


ICD‐9‐CM

vs.

ICD‐10‐CM

• 3‐5 characters in length • 3‐7 characters in length

• 1st character may be alpha, but is usually numeric; 2nd‐5th characters are numeric

• Character 1 is alpha, character 2 is always numeric, characters 3‐7 can be either alpha or numeric

• Approximately 14,000 codes • Approximately 69,000 codes

• Limited space for adding new codes • Flexibility for adding new codes

• Lacks detail • Very specific

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Example: S12

Fracture of cervical vertebra and other parts of neck

Note: A fracture not indicated as displaced or nondisplaced should be coded to displaced

A fracture not indicated as open or closed should be coded to closed

Includes: Fracture of cervical neural arch

Fracture of cervical spine

Fracture of cervical spinous process

Fracture of cervical transverse process

Fracture of cervical vertebral arch

Fracture of neck4


Excludes Notes

The ICD‐10‐CM has two types of excludes notes (recall that ICD‐9‐CM had only one type of excludes notes).

Excludes1

Excludes2

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Excludes1 This is a “pure” excludes. It means 'NOT CODED HERE!' and the code excluded should never be used at the same time as the code above the Excludes1 note.

M48.5‐ Collapsed vertebra, not elsewhere classified

Excludes 1 Current injury‐see injury of spinepathological fracture of vertebra due to neoplasm (M84.58)

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Excludes2Means NOT INCLUDED HERE. An Excludes2 note indicates that the condition is not part of the condition represented by the code, but a patient could possibly have both conditions at the same time. In this case, it could be acceptable to use both the code and the excluded code together; such as:

M51‐ Thoracic, thoracolumbar and lumbosacral intervertebral disc disorders

Excludes2 Cervical and cervicothoracic disc disorder (M50.‐)

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“Other” or “Other Specified” ( Not Elsewhere Classified—NEC)

Use when information in the medical record provide detail for which a specific code does not exist.

Specific disease is documented but there is no diagnosis code.

“Unspecified” ( Not Otherwise Specified‐ NOS)

Use when the information in the medical record is insufficientto assign a more specific code.

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CHAPTER 13 : DISEASES OF THE MUSCULOSKELETAL SYSTEM

AND CONNECT IVE T ISSUE(M00 ‐M99)

M00‐M99

M

Chapter Organization

Image sources: http://en.wikipedia.org/wiki/File:Captainmarvel.JPG 10


This chapter BLOCK is broken down into the following categories:M00‐M02 Infectious arthropathies

M05‐M14 Inflammatory polyarthropathies

M15‐M19 Osteoarthritis

M20‐M25 Other joint disorders

M26‐M27 Dentofacial anomalies and other jaw disorders

M30‐M36 Systemic connective tissue disorders

M40‐M43 Deforming dorsopathies (e.g., kyphosis, scoliosis, spondylolysis, spondylolisthesis)

M45‐M49 Spondylopathies (e.g., osteomyelitis of vertebra, infection of intervertebral disc, discitis, spondylosis, spinal stenosis)

M50‐M54 Other dorsopathies (e.g., disc disorders, spinal instabilities, radiculopathy, sciatica, lumbago, low back pain)

M60‐M63 Disorders of muscles (e.g., myositis)

M65‐M67 Disorders of synovium and tendon (e.g., trigger finger)

M70‐M79 Other soft tissue disorders (e.g., spinal synovial cyst)

M80‐M85 Disorders of bone density and structure (e.g., osteoporosis with current pathological fracture, pathological fracture in neoplastic disease)

M86‐M90 Other osteopathies (e.g., osteomyelitis, osteonecrosis)

M91‐M94 Chondropathies

M95 Other disorders of the musculoskeletal system and connective tissue

M96 Intraoperative and postprocedural complications and disorders of musculoskeletal system, not elsewhere classified (e.g., fracture following insertion of implant, puncture, laceration, hemorrhage)

M99 Biomechanical lesions, not elsewhere classified

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SPINE DISORDER WHERE YOU’LL FIND IT

Stenosis, disc, spondylolisthesis, spondylosis, degenerative scoliosis/kyphosis

M40‐M99.9 Musculoskeletal ChapterChapter 13

Spine fractures, spinal cord injury, traumatic disc, subluxation, etc

S12‐ S34.9‐ Injuries, Poisonings and Other Consequences of External Causes Chapter 19

Spinal and vertebral tumors C and D Neoplasms Chapter 2

Spinal abscesses, cysts, chronic pain, dural tear

G00‐G99.8 Nervous System Chapter 6

Complications of devices ( spine hardware, neurostimulator, etc)Post‐op wound infection, spine

T81‐T88.9 Injuries, Poisonings and Other Consequences of External Causes Chapter 19

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SPINE DISORDER WHERE YOU’LL FIND IT

Stenosis, disc, spondylolisthesis, spondylosis, degenerative scoliosis/kyphoses

M40‐M99.9 Musculoskeletal ChapterChapter 13

Spine fractures, spinal cord injury, traumatic disc, subluxation, etc

S12‐ S34.9‐ Injuries, Poisonings and Other Consequences of External Causes Chapter 19

Spinal and vertebral tumors C and D Neoplasms Chapter 2

Spinal abscesses, cysts, chronic pain, dural tear G00‐G99.8 Nervous System Chapter 6

Complications of devices ( spine hardware, neurostimulator, etc)Post‐op wound infection, spine

T81‐T88.9 Injuries, Poisonings and Other Consequences of External Causes Chapter 19

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Major Differences for Non‐Traumatic Spine?

Site specific, (occipito‐atlanto‐axial, high cervical)

Combination codes (with myelopathy and radiculopathy)

Character X and the 7Th character for healing status

Clinical concepts added (radiculopathy)

Codes expanded (increased sites and increased categories of codes)

Complications expanded

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M40: Kyphosis and lordosis

M40.‐ Postural

M40.1‐ Other secondary kyphosis

M40.2‐ Other and unspecified kyphosis

M40.3‐ Flatback syndrome

M40.4‐ Postural lordosis, acquired lordosis

M40.5‐ Lordosis, unspecified

Tip: Use M96.‐ for post‐procedural kyphosis, scoliosis, etc.

Additional character(s) required for specific spinal region for the M40‐M43 code block.

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M41: Scoliosis M41.0‐ Infantile idiopathic scoliosis

M41.1‐ Juvenile and adolescent idiopathic scoliosis

M41.2‐ Other idiopathic scoliosis

M41.3‐ Thoracogenic scoliosis

M41.4‐ Neuromuscular scoliosis (e.g., scoliosis secondary to cerebral palsy)

M41.5‐ Other secondary scoliosis

M41.8‐ Other forms of scoliosis

M41.9 Scoliosis, unspecified

Additional character(s) required for specific spinal region for the M40‐M43 code block.

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M43.0‐ Spondylolysis

M43.1‐ Spondylolisthesis (excludes traumatic and congenital)

0 site unspecified

1 occipito‐atlanto‐axial (C1‐C2)

2 cervical

3 Cervicothoracic

4 thoracic

5 thoracolumbar

6 Lumbar

7 lumbosacral

8 sacral and sacrococcygeal

9 multiple sites

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M47.82‐Other Spondylosis with

Radiculopathy

M47.1‐ Spondylosis

5th Character

0 Site unspecified

1 Occipito‐atlanto‐axial (Occiput – C2)

2 Cervical (C1 – C7)

3 Cervicothoracic (C7 – T1)

4 Thoracic (T1 – T12)

5 Thoracolumbar (T12 – L1)

6 Lumbar (L1 – L5)

7 Lumbosacral (L5 – S1)

8 Sacral and sacrococcygeal

6th Character









9 Site unspecified

M47.1‐Other spondylosis with Myelopathy

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M47.81‐Spondylosis without myelopathy or

radiculopathy

M47.‐ Spondylosis

6th Character









9 Site unspecified

19

M47.89‐ Other spondylosis, by site

M47.9 Spondylosis, unspecified

M48.0‐ Spinal stenosis

5th Character

0 Site unspecified









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M54.01‐ Radiculopathy

5th Character

0 Site unspecified









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New in ICD‐10

M46.2‐ Osteomyelitis of vertebra M46.4‐ Discitis

5th Character

0 Site unspecified









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M50.‐ Cervical: requires 5th character for all subcategories listed below

5th Character

0 Unspecified region

1 High cervical region (C2‐C3, C3‐C4)

2 Mid‐cervical region (C4‐C5, C5‐C6, C6‐C7)

3 Cervicothoracic region (C7‐T1)

M50.0‐ With myelopathy

M50.1‐ With radiculopathy

M50.2‐ Other disc displacement

M50.3‐ Other disc degeneration

M50.8‐ Other disc disorders

M50.9 Unspecified

Code to the most superior level!

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M51.‐ Thoracic, thoracolumbar and lumbosacral: requires 5th character for all subcategories listed below

5th Character

4 Thoracic (T1‐T12)

5 Thoracolumbar (T12‐L1)

6 Lumbar (L1‐L5)

7 Lumbosacral (L5‐S1)

M51.0‐ With myelopathy M51.1‐ With radiculopathy M51.2‐ Other disc displacement M51.3‐ Other disc degeneration

M51.4‐ Schmorl’s nodes M51.8‐ Other disc disorders M51.9 Unspecified

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M54.2 Cervicalgia

M54.3‐ Sciatica

New!! Unspecified side, right, left

M54.4‐ Lumbago with sciatica

New!! Unspecified side, right, left

M54.5 Low back pain

M54.6 Pain in thoracic spine

M54.9 Dorsalgia, unspecified.

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Code symptoms only when a more definite diagnosis is not known.

M96 Intraoperative and postprocedural complications and disorders of musculoskeletal system, not elsewhere classified.

Examples:

M96.0 Pseudarthrosis after fusion or arthrodesis

M96.1 Postlaminectomy syndrome, not elsewhere classified

M96.81‐ Intraoperative hemorrhage and hematoma

M96.83‐ Postprocedural hemorrhage and hematoma

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“Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.”

For example: Code the primary reason for the visit (lumbar stenosis) but code underlying conditions if they affect your treatment/surgical plan. For example, are you sending the patient to their cardiologist for a pre‐op evaluation for co‐existing cardiac conditions? Code those conditions. Important for risk based contracting and potential future payment models such as bundled payments and ACOs.

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“X” placeholder is used to provide room for future expansion

“X” placeholder is used to keep applicable 7th character in the 7th position when the code is less than 6 characters long.

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M53.2 Spinal instabilities

M53.2X1 Spinal instabilities, occipito‐atlanto‐axial region

M53.2X2 Spinal instabilities, cervical region

M53.2X3 Spinal instabilities, cervicothoracic region

M53.2X4 Spinal instabilities, thoracic region

Etc.

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“X” placeholder is used to provide room for future expansion.

“X” placeholder is used to keep the 7th character in the 7th

position when a code is less than 6 characters long.

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For Fractures 6 optionsThe appropriate 7th character is to be added to each code from category S02

A ‐ initial encounter for closed fracture

B ‐ initial encounter for open fracture

D ‐ subsequent encounter for fracture with routine healing

G ‐ subsequent encounter for fracture with delayed healing

K ‐ subsequent encounter for fracture with nonunion

S ‐ sequela

For Non‐Fractures 3 optionsThe appropriate 7th character is to be added to each code from category S14

A ‐ initial encounter

D ‐ subsequent encounter

S ‐ sequela

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Initial Encounter (A, B) = In Active Treatment

Examples include: surgical treatment, emergency department encounter and evaluation and continuing treatment by a new or the same

physician. (2015 Guideline update!)

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Subsequent Encounter (D, G, K, P) = In Healing or Recovery Phase

Examples include: cast change or removal, an x‐ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition

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Sequela (S) = Late effect, residual effect of a prior condition‐ not a complication

Examples include: scar formation resulting from a burn, deviated septum due to nasal fracture, infertility due to tubal occlusion from prior disease

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Diagnosis

(ICD‐10‐CM) Coding

Procedure

(CPT) CodingTerm Encounter VisitType Initial: the patient is in the

active phase or treatment for an injury or fracture

New patient: the patient has not been seen by the physician or other qualified health care provider in the same specialty, same group in the past 3 years

Subsequent: after the active treatment phase is over

Established patient: the patient has been seen by a physician or other qualified health care provider in the same specialty, same group practice within the past 3 years

7th Character

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36


37

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Chapter Highlights – Pathologic Fracture/ Osteoporosis Related

M80

M80.08‐ √ x 7th

Osteoporosis with current pathological fracture, vertebra(e)

M80.88‐ √ x 7th

Other osteoporosis with current pathological fracture, vertebra(e)

39Image source: http://upload.wikimedia.org/wikipedia/commons/1/17/Blausen_0250_CompressionFracture_Vertebrae.png

Chapter Highlights –Pathologic Fracture in Neoplastic Disease

M84

M84.58‐ √ x 7th

Pathological fracture in neoplastic disease, other specified site (vertebrae)

Code also underlying neoplasm

Image source: http://upload.wikimedia.org/wikipedia/commons/1/17/Blausen_0250_CompressionFracture_Vertebrae.png 40


Coding of Pathologic Fractures

For pathological fractures

The appropriate 7th character

A initial encounter for fracture

D subsequent encounter for fracture w/ routine healing

G subsequent encounter for fracture w/ delayed healing

K subsequent encounter for fracture w/ nonunion

P subsequent encounter for fracture w/ malunion

S sequela

41Image source: http://upload.wikimedia.org/wikipedia/commons/1/17/Blausen_0250_CompressionFracture_Vertebrae.png

Fatigue fractures (M48.40‐M48.48) (A type of stress fracture due to abnormal stress on normal bone)

Collapsed vertebra (M48.50‐M48.58 Codes)

Each of these categories of codes will need an X placeholder for a valid code.

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For fatigue fractures and collapsed vertebra 4 options

The appropriate 7th character is to be added to each code

A ‐ initial encounter for closed fracture

D ‐ subsequent encounter for fracture with routine healing

G ‐ subsequent encounter for fracture with delayed healing

S ‐ sequela

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All will require a 7th character:

T81.4 Infection following a procedure

T84.84 Pain due to orthopedic internal prosthetic device, implants and grafts. (painful hardware)

T85.1‐Mechanical complication of implanted electronic stimulator of nervous system ( codes for breakdown, displacement, other)

T84.2‐ Breakdown, displacement, other of internal fixation device of vertebrae

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3 options

The appropriate 7th character is to be added to each code

A ‐ initial encounter

D ‐ subsequent encounter

S ‐ sequela

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1. C3‐C7 spondylosis with myelopathy

M47.12 Spondylosis with myelopathy

EXERCISES

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2. L4‐L5 spinal stenosis, herniated disc and spondylolisthesis

EXERCISES

M48.06 Stenosis lumbar region

M51.26 Herniated lumbar disc

M43.16 Spondylolisthesis47

3. L4‐L5 spinal stenosis


EXERCISES

48


4. L4‐S1 spinal stenosis

EXERCISES


M48.07 Stenosis lumbosacral region

Teaching point: 2 diagnoses may be needed ‐ who knows?

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5. C5‐C6 herniated disc. Radiculopathy

EXERCISES

M50.12 Herniated disc with radiculopathy, mid‐cervical region

Teaching point: ICD‐10‐CM includes specific spinal regions of “high,” “mid” and junctional for some codes.

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6. L5‐S1 herniated disc

M51.27 Other lumbosacral disc displacement

EXERCISES

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7. L4 radiculopathy

M54.16 Radiculopathy, lumbar

Teaching point: Code did not exist in ICD‐9‐CM.

EXERCISES

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8. Low back pain

M54.5 Lumbago

EXERCISES

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M71.38 Other bursal cyst, other site

M48.06 Stenosis, lumbar

9. Synovial cyst at L4‐L5. Stenosis at L3‐L5

EXERCISES

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M84.58XA Pathological fracture in other disease, other site

M46.44 Discitis, unspecified, thoracic region

10. Operative note shows the following – Postoperative diagnosis: T4 pathologic fracture secondary to osteodiscitis

EXERCISES

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M84.58XA Pathologic fracture due to neoplastic disease

C79.51 Vertebral mets

Teaching point: Code also underlying neoplasm.

11. T12 pathologic fracture due to metastatic lung cancer at time of vertebral augmentation procedure

EXERCISES

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12. L4‐L5 osteomyelitis

M46.26 Osteomyelitis of vertebra, lumbar region

EXERCISES

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13. Pseudoarthrosis L4‐L5

M96.0 Pseudoarthrosis after fusion or arthrodesis

EXERCISES

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14. Lumbar instability, lumbar stenosis

1) M53.2X6 Spinal instabilities, lumbar region

2) M48.06 Stenosis, lumbar region

EXERCISES

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M43.16 Spondylolisthesis, lumbar region

M51.36 Other intervertebral disc degeneration, lumbar region

M48.06 Stenosis, lumbar region

15. Post‐op diagnosis; Spondylolisthesis, grade 1, L4‐L5, degenerative disc disease lumbar spine, spinal stenosis, neural foraminal stenosis, lumbago, sciatica

EXERCISES

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karenzupkoandassociates@[email protected]

312.642.5616www.karenzupko.comTeri Romano

RN, MBA, CPC, CMDP

Documents

ICD 10 CM IMPLEMENTATION DATE OCT 1, 2015 - Inova · ICD‐10‐CM IMPLEMENTATION DATE OCT 1, 2015 2. ... M40‐M43 Deforming dorsopathies (e.g., kyphosis, scoliosis, spondylolysis,