ICD 10 CM DOCUMENTATION TIPS & CODE EXAMPLES

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Richard Lewis
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1 WORKSHOP 2: Orthopedic / Podiatry / Spine ICD 10 CM DOCUMENTATION TIPS & CODE EXAMPLES Ready. Set. Code! ICD 10 CM by Specialty NJHA Healthcare Business Solutions

2 ARTERIOSCLEROSIS OF EXTREMITIES When documenting Arteriosclerosis of extremities, be sure to include the following: 1. Type of vessel Native artery Bypass graft o Autologous vein o Nonautologous biological o Nonbiological o Other o Unspecified Other arteries 2. Complications / Manifestations Gangrene Intermittent claudication Rest pain Ulceration o Document site: thigh / calf / ankle / heel and midfoot, etc. Other Unspecified 3. Severity of ulcer (if present) Limited to breakdown of skin With fat layer exposed With necrosis of muscle With necrosis of bone Unspecified 4. Laterality Right / Left / Bilateral / Other / Unspecified 5. Unspecified atherosclerosis 6. Generalized atherosclerosis 7. Chronic total occlusion of artery I Unspecified Atherosclerosis of native arteries of extremities, left leg I Atherosclerosis of native arteries of extremities with rest pain, right leg

3 ARTHRITIS There are specific codes for primary and secondary arthritis in ICD 10 CM. Within the secondary arthritis codes there are specific codes for post traumatic osteoarthritis and other secondary osteoarthritis For secondary osteoarthritis of the hip there is also a code for dysplastic osteoarthritis ICD 10 provides more options for the coding osteoarthritis related encounters, including: Generalized forms of osteoarthritis or arthritis where multiple joints are involved. Localized forms of osteoarthritis with more specificity that includes primary versus secondary types, subtypes, laterality, and joint involvement. When documenting arthritis, be sure to include the following also: 1. Indicate the type, location, and specific bones and joints (multiple sites if applicable) involved in the disease 2. Describe any related underlying diseases or conditions 3. Laterality M Primary osteoarthritis right hand M Secondary osteoarthritis, right hand M Rheumatoid myopathy with rheumatoid arthritis of left wrist M17.31 Unilateral post traumatic osteoarthritis of right knee M17.0 Bilateral primary osteoarthritis of knee

4 FRACTURES When documenting fractures, be sure to include the following: 1. Type Open, closed, pathological, neoplastic disease, stress 2. Pattern Comminuted, oblique, segmental, spiral, transverse 3. Etiology To document in the external cause codes (traumatic, pathologic) 4. Encounter of care Initial, subsequent, sequelae 5. Healing status, if subsequent encounter Normal healing, delayed healing, nonunion, malunion 6. Localization Shaft, head, neck, distal, proximal, styloid 7. Displacement Displaced, non displaced 8. Classification Gustilo Anderson, Salter Harris, etc. 9. Any complications, whether acute or delayed Direct result of trauma sustained It may be necessary to document intra articular or extra articular involvement For certain conditions, the bone may be affected at the proximal or distal end. Although the portion of the bone affected may be at the joint at either end, the site designation will be the bone, not the joint S52.521A Torus fracture of lower end of right radius, initial encounter for closed fracture S52.521D S42.021K Torus fracture of lower end of right radius, subsequent encounter for fracture with routine healing Displaced fracture of the shaft of right clavicle, subsequent for fracture with nonunion

5 INJURIES ICD 9 used E codes to record external causes of injury. ICD 10 better incorporates these codes and expands sections on poisonings and toxins When documenting injuries, be sure to include the following: 1. Episode of Care Initial, subsequent, sequelae 2. Injury site Be specific (for example, document exact finger lacerated) 3. Etiology How was the injury sustained Sports, motor vehicle, pedestrian, slip and fall, environmental exposure etc. 4. Place of Occurrence School, work, home, doctor s office, etc. Initial encounters may also require: 1. Intent Unintentional or accidental, self harm, etc. 2. Status Civilian, military, etc. A patient fractured his left collar bone shaft while driving his car into a pole on a local road while he was talking on his iphone. The injury occurred due to the airbag deployment. S42.025A Fracture of left collar bone shaft V47.52XA Driver of other type of car W22.11XA Airbag Y Local Road Y93.C2 Phone

6 PRESSURE ULCER When documenting a Pressure Ulcer, be sure to include the following: 1. Site 2. Stage Stage 1 Stage 2 Stage 3 Stage 4 Ankle Back o Lower o Upper o Unspecified Buttock Contiguous sites of back, buttock, hip Elbow Head o Face Heel Hip Sacral region o Coccyx, tailbone Unstageable Unspecified 3. Laterality Right Left Unspecified Code Category L89 Pressure Ulcer L Pressure ulcer of left heel, stage 3 L Pressure ulcer of right elbow, unstageable L Pressure ulcer of unspecified part of back, stage 1

7 SPINE DISORDERS When documenting Spine Disorders, be sure to include the following: 1. Type: Cervical Disc disorders Intervertebral Disc disorders Spinal instabilities Radiculopathy Sciatica Spondylosis Disc degeneration With myelopathy With radiculopathy 2. Location C0, C1, C2 Mid cervical Cervicothoracic Thoracic Thoracolumbar Lumbar Lumbosacral Sacral Sacrococcygeal M54.13 Radiculopathy, Cervicothoracic region M Spondylosis without myelopathy or radiculopathy, lumbosacral region M51.27 other intervertebral disc displacement, lumbosacral region M51.06 Intervertebral disc disorders with myelopathy, lumbar region

8 NOTES

ICD-10 Service Line Overview Musculoskeletal

ICD-10 Service Line Overview Musculoskeletal ICD-10 incorporates much greater clinical detail and specificity as well as updated terminology to be consistent with current clinical practices. ICD-10-CM