Diseases of the Musculoskeletal System and Connective Tissue M51 M99 (Part 2)

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1 Diseases of the Musculoskeletal System and Connective Tissue M51 M99 (Part 2) Presented by David Freedman, DPM, CPC, CSFAC, CPMA Webinar 5b: Thursday, April 3,

2 APMA Educational Information: ICD-10 Webinars Register for upcoming webinars View archived recordings Download PDF versions of each presentation apma.org/icd10ishere or apma.org/webinars Coding Resource Center apmacodingrc.org Questions Contact the Health Policy and Practice Department or

3 APMA Upcoming Webinars: 3

4 APMA Upcoming Seminars: 4

5 ICD-10-CM Resources 5

APMA Coding Resource Center www.apmacodingrc.

6 APMA Coding Resource Center ICD-9 to ICD-10 crosswalks are now available. 6

7 APMA Coding Resource Center 7

8 APMA Coding Resource Center 8

9 ICD-10-CM Rules M51-M99 MSK Part 2 Chapter 13: Diseases of the musculoskeletal system and connective tissue (M00-M99) Note: Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition. 9

10 Tonight we continue with M77 and finish the MSK 10

11 ICD-10 Review of some Rules SYMBOLS and CONVENTIONS Reviewed 1) The Excludes 1 is when two conditions can not occur together. 2) The Excludes 2 means not included here. This is the case where it is acceptable to use both the code and the excluded code together. 3) The Code first/use additional code means when there are multiple body system manifestations you code the underlying condition first and the manifestation second. 11

12 Chief Complaint: Doc there is pain you know right here, directly under the ball of the right foot in the middle, you know. 12

13 Musculoskeletal: Inspection and palpation reveals the right foot exhibits generalized pain to the ball of the foot but no pain was noted in the interspace along the nerve. Impression: Metatarsalgia, right foot. 13

14 Go to Index first Metatarsalgia M anterior G Morton's G

15 Go to the Tabular M77.4 Metatarsalgia Excludes1: Morton's metatarsalgia (G57.6) M77.40 Metatarsalgia, unspecified foot M77.41 Metatarsalgia, right foot M77.42 Metatarsalgia, left foot 15

16 ICD 9 ICD Metatarsalgia M77.41 Metatarsalgia, right foot 16

17 Chief Complaint: Doc there is burning and tingling in front of the left ankle and along the outside of the ankle and foot too. 17

18 Musculoskeletal: Inspection and palpation reveals the left ankle and foot exhibits no MSK deformities. Neurological: There inflammation noted along the Intermediate dorsal cutaneous nerve and the Sural nerve along the left foot and ankle. Impression: Neuritis, left ankle and foot 18

19 Go to Index first Neuralgia, neuralgic (acute) M79.2 Neuritis (rheumatoid) M

20 Go to the Tabular M79.2 Neuralgia and neuritis, unspecified Excludes1: brachial radiculitis NOS (M54.1) lumbosacral radiculitis NOS (M54.1) mononeuropathies (G56-G58) radiculitis NOS (M54.1) sciatica (M54.3-M54.4) 20

21 ICD 9 ICD Neuralgia and neuritis, unspecified M79.2 Neuralgia and neuritis, unspecified 21

22 Chief Complaint: There is pain everywhere. Today there is pain and tenderness in the legs, tops of the feet and the toes. 22

23 Musculoskeletal: Inspection and palpation reveals the left and right lower legs, ankles and feet exhibits generalized aches and pains anywhere this patient is examined. Impression: Fibromyalgia left and right lower legs, ankles and feet 23

24 Go to Index first Fibromyalgia M

25 Go to the Tabular M79.7 Fibromyalgia Fibromyositis Fibrositis Myofibrositis 25

26 ICD 9 ICD Fibromyalgia M79.7 Fibromyalgia 26

27 Chief Complaint: There is pain in the front of the right ankle and top of the right foot. 27

28 Musculoskeletal: Inspection and palpation reveals a generalized right ankle and foot pain. Impression: Pain in the right ankle and foot. 28

29 ICD 10 go to the Index Pain - foot see Pain, limb, lower - limb M lower M foot M lower leg M thigh M toe M

30 ICD 10 Go to the Tabular M79.6 Pain in limb, hand, foot, fingers and toes Excludes2: pain in joint (M25.5-) M79.60 Pain in limb, unspecified M Pain in right leg Pain in right lower limb NOS M Pain in left leg Pain in left lower limb NOS M Pain in leg, unspecified Pain in lower limb NOS M Pain in unspecified limb Pain in limb NOS Comment: At first this seems adequate but it is not to highest level of specificity, so we keep going 30

31 ICD 10 go to the Tabular M79.66 Pain in lower leg M Pain in right lower leg M Pain in left lower leg M Pain in unspecified lower leg (*Comment: Pain in right ankle is included in lower leg*) 31

32 Go to the Tabular M79.67 Pain in foot and toes M Pain in right foot M Pain in left foot M Pain in unspecified foot M Pain in right toe(s) M Pain in left toe(s) M Pain in unspecified toe(s) 32

33 ICD 9 ICD Pain Pain M Pain in right lower leg M Pain in right foot 33

34 Chief Complaint: A 90 year old female presents today relating there is pain in the right foot that just started to be painful after walking the family dog this past weekend with my family in their neighborhood. 34

35 Musculoskeletal: Inspection and palpation reveals localized pain to the right foot 2 nd metatarsal. Radiologic Examination: AP, Lateral and Medial Oblique views reveals an oblique fracture of the 2 nd metatarsal, there is spotty diffuse loss of bone density throughout all the metatarsals. Impression: Osteoporosis with a 2 nd metatarsal fracture in the right foot 35

36 ICD 10 go to the Index Fracture, pathological (pathologic) see also Fracture, traumatic M ankle M fibula M metatarsus M tarsus M tibia M toe M osteoporosis M

37 ICD 10 go to the Index Osteoporosis (female) (male) M with current pathological fracture M fibula M metatarsus M tarsus M tibia M toe M

38 ICD 10 go to the Tabular M80 Osteoporosis with current pathological fracture Includes: Osteoporosis with current fragility fracture Use additional code to identify major osseous defect, if applicable (M89.7-) Excludes1: collapsed vertebra NOS (M48.5) pathological fracture NOS (M84.4) wedging of vertebra NOS (M48.5) 38

39 M80 Osteoporosis with current pathological fracture - Cont d Excludes2: personal history of (healed) osteoporosis fracture (Z87.310) The appropriate 7th character is to be added to each code from category M80: A - initial encounter for fracture D - subsequent encounter for fracture with routine healing G - subsequent encounter for fracture with delayed healing K - subsequent encounter for fracture with nonunion P - subsequent encounter for fracture with malunion S - sequela 39

40 Go to the Tabular M80.07 Age-related osteoporosis with current pathological fracture, ankle and foot M Age-related osteoporosis with current pathological fracture, right ankle and foot M Age-related osteoporosis with current pathological fracture, left ankle and foot M Age-related osteoporosis with current pathological fracture, unspecified ankle and foot 40

41 Go Back to the Tabular and find Activity Y93.0 Activities involving walking and running Excludes1: activity, walking an animal (Y93.K1) activity, walking or running on a treadmill (Y93.A1) Y93.01 Activity, walking, marching and hiking Activity, walking, marching and hiking on level or elevated terrain Excludes1: activity, mountain climbing (Y93.31) 41

42 But must continue in the Tabular and find her specific activity Y93.K Activities involving animal care Excludes1: activity, horseback riding (Y93.52) Y93.K1 Activity, walking an animal Y93.K2 Activity, milking an animal Y93.K3 Activity, grooming and shearing an animal Y93.K9 Activity, other involving animal care 42

43 ICD 9 ICD Fracture Metatarsal Osteoporosis (postmenopausal) No code M80.071A Age-related osteoporosis with current pathological fracture, right ankle and foot, initial encounter Y93.K1 Activity, walking an animal 43

44 So, what if this patient only had Osteoporosis and no fracture that is coded? 44

45 ICD 10 go to the Index Osteoporosis (female) (male) M with current pathological fracture M fibula M metatarsus M tarsus M tibia M toe M

46 ICD 10 go to the Tabular-Rules M81 Osteoporosis without current pathological fracture Use additional code to identify: major osseous defect, if applicable (M89.7-) personal history of (healed) osteoporosis fracture, if applicable (Z87.310) Excludes1: osteoporosis with current pathological fracture (M80.-) Sudeck's atrophy (M89.0) 46

47 Go to the Tabular M81.0 Age-related osteoporosis without current pathological fracture Involutional osteoporosis without current pathological fracture Osteoporosis NOS Postmenopausal osteoporosis without current pathological fracture Senile osteoporosis without current pathological fracture 47

48 ICD 9 ICD Osteoporosis (postmenopausal) M81.0 Age-related osteoporosis without current pathological fracture 48

49 Chief Complaint: A high school male athlete relates training for cross country this past week ever afternoon, after school, he said he developed right shin pain about 5 miles into the run yesterday and it hurts. 49

50 Musculoskeletal: Inspection and palpation reveals localized pain to the right anterior tibia. Radiologic Examination: AP, Lateral and Medial Oblique views reveals a possible oblique fracture of the right lower leg revealed no bony abnormality. The x-rays are not definitive. MRI: Revealed bone marrow changes in the anterior tibia suggesting stress injury. Impression: Stress Fracture of the right tibia 50

51 ICD 10 go to the Index Fracture - stress M ankle M fibula M metatarsus M tarsus M tibia M

52 ICD 10 go to the Tabular-Rules M84.3 Stress fracture Fatigue fracture March fracture Stress fracture NOS Stress reaction Use additional external cause code(s) to identify the cause of the stress fracture Excludes1: pathological fracture NOS (M84.4.-) pathological fracture due to osteoporosis (M80.-) traumatic fracture (S12.-, S22.-, S32.-, S42.-, S52.-, S62.-, S72.-, S82.-, S92.-) 52

53 ICD 10 go to the Tabular-Rules M84.3 Stress fracture - continued Excludes2: personal history of (healed) stress (fatigue) fracture (Z87.312) stress fracture of vertebra (M48.4-) The appropriate 7th character is to be added to each code from subcategory M84.3: A - initial encounter for fracture D - subsequent encounter for fracture with routine healing G - subsequent encounter for fracture with delayed healing K - subsequent encounter for fracture with nonunion P - subsequent encounter for fracture with malunion S - sequela 53

54 Go to the Tabular M84.36 Stress fracture, tibia and fibula M Stress fracture, right tibia M Stress fracture, left tibia M Stress fracture, right fibula M Stress fracture, left fibula M Stress fracture, unspecified tibia and fibula 54

55 ICD 9 ICD Stress fracture, other M84.361A Stress fracture, right tibia, initial encounter 55

56 Go back to the Tabular and obtain the external cause code, in this example the cause was running 56

57 Y93.0 Activities involving walking and running Excludes1: activity, walking an animal (Y93.K1) activity, walking or running on a treadmill (Y93.A1) Y93.01 Activity, walking, marching and hiking Activity, walking, marching and hiking on level or elevated terrain Excludes1: activity, mountain climbing (Y93.31) Y93.02 Activity, running 57

58 ICD 9 ICD 10 No code Y93.02 Activity, running 58

59 Putting it all together: ICD 9 ICD Stress fracture, other No Code M84.361A Stress fracture, right tibia, initial encounter Y93.02 Activity, running 59

60 Chief Complaint: The daughter is here relating her mom had this red area around the outside of the right ankle. It was related that it seemed to get red and swollen then black just over the weekend. 60

61 Musculoskeletal: Inspection and palpation reveal the right ankle primarily along the fibula is erythematous, it has increased temperature with localized pain. There is an ulcer that probes to bone. Radiologic examination: AP, Lateral and Oblique views reveal destructive changes to the right fibula, the lateral malleolus. MRI: Revealed bone marrow edema changes in the right lateral malleolus and lysis of the cortex. Impression: Osteomyelitis lateral malleolus, right fibula 61

62 ICD 10 go to the Index Osteomyelitis (general) (infective) (localized) (neonatal) (purulent) (septic) (staphylococcal) (streptococcal) (suppurative)(with periostitis) M acute M fibula M hematogenous M fibula M metatarsus M multiple sites M

63 ICD 10 go to the Tabular-Rules M86 Osteomyelitis Use additional code (B95-B97) to identify infectious agent Use additional code to identify major osseous defect, if applicable (M89.7-) Excludes1: osteomyelitis due to: echinococcus (B67.2) gonococcus (A54.43) salmonella (A02.24) 63

64 ICD 10 go to the Tabular-Rules M86 Osteomyelitis continued Excludes2: ostemyelitis of: orbit (H05.0-) petrous bone (H70.2-) vertebra (M46.2-) 64

65 Go to the Tabular M86.06 Acute hematogenous osteomyelitis, tibia and fibula M Acute hematogenous osteomyelitis, right tibia and fibula M Acute hematogenous osteomyelitis, left tibia and fibula M Acute hematogenous osteomyelitis, unspecified tibia and fibula ***Can t stop here*** 65

66 Go to the Tabular M86.07 Acute hematogenous osteomyelitis, ankle and foot M Acute hematogenous osteomyelitis, right ankle and foot M Acute hematogenous osteomyelitis, left ankle and foot M Acute hematogenous osteomyelitis, unspecified ankle and foot ***Can t stop here*** 66

67 Go to the Tabular M86.16 Other acute osteomyelitis, tibia and fibula M Other acute osteomyelitis, right tibia and fibula M Other acute osteomyelitis, left tibia and fibula M Other acute osteomyelitis, unspecified tibia and fibula 67

68 Go to the Tabular M86.17 Other acute osteomyelitis, ankle and foot M Other acute osteomyelitis, right ankle and foot M Other acute osteomyelitis, left ankle and foot M Other acute osteomyelitis, unspecified ankle and foot 68

69 ICD 9 ICD Osteomyelitis (acute), ankle and foot Acute hematogenous osteomyelitis, ankle and foot M Right M Left Other acute osteomyelitis, ankle and foot M Right M Left 69

70 ICD 9 ICD Osteomyelitis (acute), lower leg Acute hematogenous osteomyelitis, right tibia and fibula M Right M Left Other acute osteomyelitis, right tibia and fibula M Right M Left 70

71 Can t stop here if the infection was due to MRSA. ICD 9 ICD Methicillinresistant staphylococcus aureus (MRSA) B95.62 Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere (MRSA) 71

72 Chief Complaint: This patient was brought back in by their daughter relating her mom had the open sore re-open along the outside of the right ankle, that seemed to get red and swollen then black over the weekend. HPI: This is the 4 th time this has opened up and has drainage. She has been hospitalized 3 times for the bone infection and IV antibiotics 72

73 Musculoskeletal: Inspection and palpation reveals the right ankle along the fibula at the level of the malleolus has an erythematous, increased temperature with localized pain. There is recurrent ulcer that probes to bone and is draining. Radiologic examination: AP, Lateral and Oblique views reveal destructive changes to the right fibular lateral malleolus. Impression: Chronic Osteomyelitis lateral malleolus, right 73

74 ICD 10 go to the Index Osteomyelitis (general) (infective) (localized) (neonatal) (purulent) (septic) (staphylococcal) (streptococcal) (suppurative)(with periostitis) M chronic (or old) M with draining sinus M fibula M

75 Go to the Tabular M86.46 Chronic osteomyelitis with draining sinus, tibia and fibula M Chronic osteomyelitis with draining sinus, right tibia and fibula M Chronic osteomyelitis with draining sinus, left tibia and fibula M Chronic osteomyelitis with draining sinus, unspecified tibia and fibula 75

76 Go to the Tabular M86.47 Chronic osteomyelitis with draining sinus, ankle and foot M Chronic osteomyelitis with draining sinus, right ankle and foot M Chronic osteomyelitis with draining sinus, left ankle and foot M Chronic osteomyelitis with draining sinus, unspecified ankle and foot 76

77 Go to the Tabular M86.56 Other chronic hematogenous osteomyelitis, tibia and fibula M Other chronic hematogenous osteomyelitis, right tibia and fibula M Other chronic hematogenous osteomyelitis, left tibia and fibula M Other chronic hematogenous osteomyelitis, unspecified tibia and fibula 77

78 Go to the Tabular M86.57 Other chronic hematogenous osteomyelitis, ankle and foot M Other chronic hematogenous osteomyelitis, right ankle and foot M Other chronic hematogenous osteomyelitis, left ankle and foot M Other chronic hematogenous osteomyelitis, unspecified ankle and foot 78

79 Go to the Tabular M86.66 Other chronic osteomyelitis, tibia and fibula M Other chronic osteomyelitis, right tibia and fibula M Other chronic osteomyelitis, left tibia and fibula M Other chronic osteomyelitis, unspecified tibia and fibula 79

80 Go to the Tabular M86.67 Other chronic osteomyelitis, ankle and foot M Other chronic osteomyelitis, right ankle and foot M Other chronic osteomyelitis, left ankle and foot M Other chronic osteomyelitis, unspecified ankle and foot 80

81 ICD 9 ICD Osteomyelitis (chronic), lower leg Osteomyelitis (chronic), ankle and foot Chronic osteomyelitis with draining sinus, tibia and fibula M Right M Left Chronic osteomyelitis with draining sinus, ankle and foot M Right M Left 81

82 ICD 9 ICD Osteomyelitis (chronic), lower leg Other chronic osteomyelitis, tibia and fibula M Right M Left Osteomyelitis (chronic), ankle and foot Other chronic osteomyelitis, ankle and foot M Right M Left 82

83 M89.7 Major osseous defect Code first underlying disease, if known, such as: aseptic necrosis of bone (M87.-) malignant neoplasm of bone (C40.-) osteolysis (M89.5) osteomyelitis (M86.-) osteonecrosis (M87.-) osteoporosis (M80.-, M81.-) periprosthetic osteolysis (T84.05-) M89.77 Major osseous defect, ankle and foot Major osseous defect of metatarsus, tarsus, toes M Major osseous defect, right ankle and foot M Major osseous defect, left ankle and foot 83

84 Additional Examples continuing with other ICD-10-CM Musculoskeletal Coding using the APMA Coding Resource Center 84

85 Chief Complaint: My right foot has this pain in the area under my big toe, feels like a pea in there. HPI: This is a sharp pain, localized to the area immediately inferior to the 1 st MTPJ sesamoid area, walking worsens the condition and the numbered Dr. Scholl s inserts did not help. 85

86 Musculoskeletal: Inspection and palpation reveals the right tibial sesamoid is painful, increased temperature with localized pain. There is inflammation noted when compared to the left foot Radiologic examination: AP, Lateral and Oblique views reveal hypertrophic changes to the right tibial sesamoid. Impression: Sesamoiditis, tibial, right foot 86

87 87

88 88

89 ICD 9 ICD Hypertrophy of bone (sesamoiditis) M Hypertrophy of bone, right ankle and foot But is it a hypertrophy? 89

90 What about if it is an enthesopathy? 90

91 Enthesopathy, unspecified Bone Spur NOS, Capsulitis NOS, Tendinits NOS) ICD 9 ICD Hypertrophy of bone (sesamoiditis) M77.51 Other enthesopathy of right foot M77.9 Enthesopathy, unspecified Bone Spur NOS, Capsulitis NOS, Tendinits NOS) 91

92 What about the 2014 index, it says M

93 ICD 9 ICD Hypertrophy of bone (sesamoiditis) M Other specified joint disorders, ankle and foot, right You need to decide and use the correct verbiage offered in the example. 93

94 Chief Complaint: A 11 year old boy is here with his mom, stating that the bottom of his right heel hurts. HPI: This is a sharp pain, localized to the calcaneus immediately inferiorly and is getting worse. It has been difficult walking and worsens with activity. Mom said she went to the store and followed the foot mapping from those numbered Dr. Scholl s inserts, spent a lot of money but they did not help. 94

95 Musculoskeletal: Inspection and palpation reveals the right calcaneus has localized pain along the apophysis. There is inflammation noted when compared to the left foot Radiologic examination: AP, Lateral and Oblique views reveal normal growth plate on the calcaneus however the more inferior aspect when compared to the left x-rays appears further apart by 2mm. Impression: Calcaneal Apophysitis (Severs Disease), right foot 95

96 96

97 Just to be complete, here are the other juvenile osteochondrosis.. 97

98 98

99 ICD 9 ICD Juvenile osteochondrosis of foot- Calcaneal apophysitis M92.61 Juvenile osteochondrosis of tarsus, right ankle - Osteochondrosis (juvenile) of calcaneum [Sever] M92.8 Other specified juvenile osteochondrosis Calcaneal apophysitis So which diagnosis do you choose? 2 possibilities-based on your description 99

100 Chief Complaint: Doc the area that you did my fusion is swollen and hurts when walking HPI: This is a sharp pain, localized to the 1 st MTPJ right foot, seems unstable with walking he relates and is getting worse for 6 months did not want to come back was afraid of what you might say. It has been difficult walking and worsens with activity. 100

101 Musculoskeletal: Inspection and palpation reveals the right 1 st MTPJ fusion site is not rigid, appears to have motion which was not intended. There is inflammation noted when compared to the left foot Radiologic examination: AP, Lateral and Oblique views reveal the 1 st MTPJ fusion site is not healed, there is shadowing within the fusion but it is not calcified. Impression: Pseudoarthrosis of the 1 st MTPJ, right foot 101

102 102

103 103

104 ICD 9 ICD Nonunion of fracture Pseudoarthrosis (bone) M96.0 Pseudarthrosis after fusion or arthrodesis 104

105 Chief Complaint: Doc the area that I had my right foot surgery is very sore, swollen and bruised feeling. HPI: Surgery was performed for a midfoot ostectomy, right foot. Area is ecchymotic, he has been icing and elevating the foot as prescribed and taking post-op pain medication hydrocodone every 4-6 hours. 105

106 Musculoskeletal: Inspection and palpation reveals the right foot 1 st Metatarsal cuneiform joint surgical site is coapted well but there is extensive post operative ecchymosis subcutaneously. Radiologic examination: AP, Lateral and Oblique views reveal the 1 st metatarsal cuneiform site shows adequate resection of bone, none of the exostoses exist. Impression: Post procedural hematoma of the musculoskeletal structure, 1 st Metatarsal cuneiform joint, right foot, following the musculoskeletal procedure. 106

107 107

108 ICD 9 ICD Hemorrhage complicating a procedure Hematoma complicating a procedure M Postprocedural hemorrhage and hematoma of a musculoskeletal structure following a musculoskeletal system procedure 108

109 Next Webinar Webinar 6: Injuries (S00-T88) Thursday, April 17, 2014 at 8:00 PM ET Presented by Andy Bhatia, DPM Register at 109

110 Questions? 110

Diseases of the Musculoskeletal System and Connective Tissue M00 M50 (Part 2)

Diseases of the Musculoskeletal System and Connective Tissue M00 M50 (Part 2) Presented by Lawrence Santi, DPM, FASPS Webinar 4b: Thursday, March 6, 2014 1 APMA Educational Information: ICD-10 Webinars