ICD-10-CM Coding Workbook for Orthopaedics

Specialty coding guidance for ICD-10-CM

2017

© 2016 Optum360, LLC i

Contents

Introduction .............................................................................................................................................. 1Overview of ICD-10 .............................................................................................................................................................................................. 1Getting Ready for ICD-10 ................................................................................................................................................................................... 2

Using This ICD-10-CM Workbook ..................................................................................................................................................................... 2Workbook Guidelines .......................................................................................................................................................................................... 3Online Exams to Test Your ICD-10-CM Coding Skills ................................................................................................................................... 4Summary ................................................................................................................................................................................................................ 4

Case Studies and Questions ...................................................................................................................... 5Case Study #1—Total Knee Arthroplasty ....................................................................................................................................................... 5Case Study #2—Radial Shaft Fracture ............................................................................................................................................................ 8Case Study #3—Total Hip Arthroplasty ........................................................................................................................................................12

Case Study #4—Periprosthetic Fracture of Femur ....................................................................................................................................14

Case Study #5—Trigger Finger Release .......................................................................................................................................................17Case Study #6—Digital Neuroma ..................................................................................................................................................................19

Case Study #7—Degenerative Joint Disease, Shoulder ...........................................................................................................................21

Case Study #8—ACL Tear ................................................................................................................................................................................23Case Study #9—Radioulnar Synostosis ........................................................................................................................................................26

Case Study #10—Lunate Stress Fracture .....................................................................................................................................................28

Case Study #11—Fracture of Thumb ............................................................................................................................................................30Case Study #12—Gangrene of Foot ..............................................................................................................................................................32

Case Study #13—Idiopathic Osteoporosis ..................................................................................................................................................35

Case Study #14—Rupture of Quadriceps Tendon .....................................................................................................................................37Case Study #15—Wrist Laceration with Tendon Injury ...........................................................................................................................40

Case Study #16—Cervical Stenosis with Myelopathy ..............................................................................................................................43

Case Study #17—Rotator Cuff and Labral Tear of Shoulder ...................................................................................................................46Case Study #18—ACL and Meniscus Injury, Knee .....................................................................................................................................49

Case Study #19—Meniscal Tear and Osteochondral Fracture, Knee ....................................................................................................51

Case Study #20—Degenerative Joint Disease, Shoulder .........................................................................................................................55Case Study #21—Status Postlumbar Decompression with Osteoporosis ...........................................................................................57

Case Study #22—Osteoarthritis and Myofascial Pain Syndrome ..........................................................................................................62

Case Study #23—Left Foot Pain .....................................................................................................................................................................64Case Study #24—Left Knee Pain ....................................................................................................................................................................67

Case Study #25—Humeral Fracture ..............................................................................................................................................................70

Case Study #26—Distal Fibular Fracture .....................................................................................................................................................73Case Study #27—Planovalgus Feet with Myotonic Muscular Dystrophy ............................................................................................77

Case Study #28—Chronic Plantar Fasciitis ..................................................................................................................................................80

Case Study #29—Posterior Calf Pain ............................................................................................................................................................82Case Study #30—Bunion and Hammer Toe ................................................................................................................................................85

Case Study #31—Erythema of the Knee ......................................................................................................................................................89

Case Study #32—Chronic Pain .......................................................................................................................................................................91Case Study #33—Back and Shoulder Pain ...................................................................................................................................................94

Case Study #34—Carpal Tunnel Syndrome ................................................................................................................................................98

Case Study #35—Lytic Lesion of Cervical Vertebrae .............................................................................................................................. 100Case Study #36—Patellar Tendon Rupture .............................................................................................................................................. 102

Case Study #37—Above-the-Knee Amputation ..................................................................................................................................... 105

Contents ICD-10-CM Coding Workbook for Orthopaedics

ii © 2016 Optum360, LLC

Case Study #38—Avascular Necrosis of Hip ............................................................................................................................................107

Case Study #39—Neck Pain Following MVA ............................................................................................................................................109

Case Study #40—Shoulder Osteoarthritis .................................................................................................................................................111Case Study #41—Trauma to Finger ...........................................................................................................................................................114

Case Study #42—Open Tibia Fibula Fracture ...........................................................................................................................................117

Case Study #43—Transmetatarsal Amputation ......................................................................................................................................119Case Study #44—Displaced Fifth Metacarpal Fracture ..........................................................................................................................121

Case Study #45—Follow-up for Tibial Plateau Fracture ........................................................................................................................123

Case Study #46—Removal of Painful Instrumentation and Placement of L5-S1 Rods ..................................................................125

Answers and Rationales ........................................................................................................................ 127Case Study #1—Total Knee Arthroplasty ..................................................................................................................................................127Case Study #2—Radial Shaft Fracture ........................................................................................................................................................129

Case Study #3—Total Hip Arthroplasty .....................................................................................................................................................131Case Study #4—Periprosthetic Fracture of Femur ..................................................................................................................................133

Case Study #5—Trigger Finger Release .....................................................................................................................................................135

Case Study #6—Digital Neuroma ................................................................................................................................................................137Case Study #7—Degenerative Joint Disease, Shoulder .........................................................................................................................138

Case Study #8—ACL Tear ..............................................................................................................................................................................140

Case Study #9—Radioulnar Synostosis ......................................................................................................................................................143Case Study #10—Lunate Stress Fracture ...................................................................................................................................................145

Case Study #11—Fracture of Thumb ..........................................................................................................................................................147

Case Study #12—Gangrene of Foot ............................................................................................................................................................149Case Study #13—Idiopathic Osteoporosis ................................................................................................................................................152

Case Study #14—Rupture of Quadriceps Tendon ...................................................................................................................................154

Case Study #15—Wrist Laceration with Tendon Injury .........................................................................................................................156Case Study #16—Cervical Stenosis with Myelopathy ............................................................................................................................158

Case Study #17—Rotator Cuff and Labral Tear of Shoulder .................................................................................................................160

Case Study #18—ACL and Meniscus Injury, Knee ...................................................................................................................................162Case Study #19—Meniscal Tear and Osteochondral Fracture, Knee ..................................................................................................164

Case Study #20—Degenerative Joint Disease, Shoulder ......................................................................................................................167

Case Study #21—Status Postlumbar Decompression with Osteoporosis .........................................................................................169Case Study #22—Osteoarthritis and Myofascial Pain Syndrome ........................................................................................................172

Case Study #23—Left Foot Pain ..................................................................................................................................................................174

Case Study #24—Left Knee Pain ..................................................................................................................................................................176Case Study #25—Humeral Fracture ............................................................................................................................................................178

Case Study #26—Distal Fibular Fracture ...................................................................................................................................................180

Case Study #27—Planovalgus Feet with Myotonic Muscular Dystrophy .........................................................................................182Case Study #28—Chronic Plantar Fasciitis ................................................................................................................................................184

Case Study #29—Posterior Calf Pain ..........................................................................................................................................................186

Case Study #30—Bunion and Hammer Toe .............................................................................................................................................188Case Study #31—Erythema of the Knee ....................................................................................................................................................190

Case Study #32—Chronic Pain .....................................................................................................................................................................192

Case Study #33—Back and Shoulder Pain ................................................................................................................................................194Case Study #34—Carpal Tunnel Syndrome ..............................................................................................................................................197

Case Study #35—Lytic Lesion of Cervical Vertebrae ..............................................................................................................................199

Case Study #36—Patellar Tendon Rupture ...............................................................................................................................................201Case Study #37—Above-the-Knee Amputation ......................................................................................................................................204

Case Study #38—Avascular Necrosis of Hip ............................................................................................................................................207

ICD-10-CM Coding Workbook for Orthopaedics Contents

© 2016 Optum360, LLC iii

Case Study #39—Neck Pain Following MVA ............................................................................................................................................ 209

Case Study #40—Shoulder Osteoarthritis ................................................................................................................................................ 211

Case Study #41—Trauma to Finger .......................................................................................................................................................... 214Case Study #42—Open Tibia Fibula Fracture .......................................................................................................................................... 216

Case Study #43—Transmetatarsal Amputation ...................................................................................................................................... 219

Case Study #44—Displaced Fifth Metacarpal Fracture ......................................................................................................................... 221Case Study #45—Follow-up for Tibial Plateau Fracture ....................................................................................................................... 223

Case Study #46—Removal of Painful Instrumentation and Placement of L5-S1 Rods ................................................................. 225

Appendix A. Quick Coding Reference ................................................................................................... 227How to Use ........................................................................................................................................................................................................ 227Spinal Conditions ............................................................................................................................................................................................ 229

ICD-10-CM Mapping ................................................................................................................................................................................ 231Fractures ............................................................................................................................................................................................................ 235

ICD-10-CM Mapping ................................................................................................................................................................................ 237

Joint Conditions and Injuries ........................................................................................................................................................................ 265ICD-10-CM Mapping ................................................................................................................................................................................ 268

Other Traumatic Injuries ................................................................................................................................................................................ 276

ICD-10-CM Mapping ................................................................................................................................................................................ 279General Musculoskeletal ............................................................................................................................................................................... 290

ICD-10-CM Mapping ................................................................................................................................................................................ 292

Appendix B. ICD-10-CM Official Guidelines for Coding and Reporting 2016 ...................................... 295Section I. Conventions, general coding guidelines and chapter specific guidelines .................................................................... 300Section II. Selection of Principal Diagnosis .............................................................................................................................................. 351Section III. Reporting Additional Diagnoses ............................................................................................................................................. 353Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services ........................................................................ 354

Case Studies and Questions ICD-10-CM Coding Workbook for Orthopaedics

64 © 2016 Optum360, LLC

Case Study #23—Left Foot Pain

DescriptionConsultation for left foot pain

Chief ComplaintLeft foot pain

HistoryThe patient is a basketball player for Optum University who was injured in a game one day prior. He jumped and came down twisting his foot and injuring it. He had an immediate onset of swelling and pain. The trainer taped up his foot and he was able to continue playing in the game. Following the game he was further examined by the trainer and had some tenderness around the navicular. The patient has been taped up firmly and in a walking boot since the game. He does have pain with any type of weightbearing activities and is limping a bit. He has not suffered any significant foot injuries in the past. The majority of the pain is located around the dorsal aspect of the hind and midfoot.

Physical ExaminationPatient has swelling from the hindfoot out toward the midfoot. The arch is maintained however. Motion at the ankle and subtalar joints is preserved, and forefoot motion is intact. He complains of pain with adduction and abduction across the hindfoot, most of the discomfort presenting laterally. Motor strength is grossly intact, as is sensation. Pulses are strong and palpable. The ankle is not tender. There is no medial tenderness over the ATFL, along the deltoid, or the medial malleolus. His anterior drawer is solid. External rotation stress is not painful at the ankle. Tarsometatarsal joints 1, 2, and 3 are nontender. The majority of tenderness is found laterally along the calcaneocuboid joint and along the anterior process of the calcaneus. The patient notes some tenderness over the dorsolateral side of the talonavicular joint as well, although the medial talonavicular joint is nontender.

RadiologyWeightbearing radiographs of the foot show changes that appear chronic over the dorsal aspect of the navicular. There does not appear to be a definite fracture. Tarsometatarsal joints are anatomically aligned. Films of the ankle show no fractures but changes along the dorsal talonavicular joint. An MR scan was also reviewed, which shows some changes along the lateral side of the calcaneocuboid joint with disruption of the capsular area and lateral ligament. It also shows some changes to the dorsal talonavicular joint, but no significant marrow edema or definitive fracture line.

ImpressionLeft Chopart joint sprain

PlanContinue with walking boot for weightbearing activities. Start a functional rehab program and progress back to activities as symptoms allow. Patient is aware that a prolonged duration of recovery is sometimes needed for this type of a hindfoot injury, and additional injury can occur if appropriate plan is not followed.

Answers and Rationales ICD-10-CM Coding Workbook for Orthopaedics

174 © 2016 Optum360, LLC

Case Study #23—Left Foot Pain

Answers

1. Assign the correct ICD-10-CM diagnosis codes for the above encounter.

S93.692A Other sprain of left foot, initial encounter

Y93.67 Activity, basketball

Y92.310 Basketball court as the place of occurrence of the external cause

This type of foot sprain can be difficult to code due to the number of different ligaments found in the foot structure. The patient suffered a Chopart joint sprain, which is a sprain of the midtarsal region of the foot. It typically involves the dorsal calcaneocuboid ligament or the bifurcate ligament. In order to find the appropriate code, main term “Sprain” and subterm “foot” should be identified in the alphabetic index. The only ligaments listed under foot are the tarsal ligament and the tarsometatarsal ligament. The most accurate choice based on the knowledge gained about Chopart joint sprains is “specified ligament NEC,” which references S93.69-. The tabular list indicates that seven characters are required for a complete code selection. Sixth character “2” represents the left foot and seventh character “A” indicates that this encounter is within the initial encounter phase of this injury.

External cause codes provide additional information about the mechanism of injury. This was a twisting injury of the foot. In the Index to External Causes, main term “Twisting” and subterm “excessive” seem to be the only appropriate option. This listing tells the coder to see category Y93. This category includes the activity codes, which describe the type of activity the patient was taking part in when the twisting injury occurred. Main term “Activity” and subterm “basketball” reference code Y93.67, which when verified in the tabular list is deemed appropriate and complete. It is also possible to indicate where the injury occurred. Main term “Place of occurrence” and subterm “basketball court” reference code Y92.310. The tabular list verifies that this is the appropriate code choice.

2. Match the following bones of the foot and ankle with the correct definition.

These bones are all part of the foot and ankle. It is vital to know and understand the bone structure of various parts of the body in order to report ICD-10-CM codes accurately.

Bones Definitions

a. Navicular__3__ 1. Sits on top of the calcaneus, also known as the ankle bone

b. Calcaneus __2__ 2. Largest tarsal bone of the foot, also called the heel bone

c. Cuboid __5__ 3. Small tarsal bone that sits at the top of the midfoot

d. Talus __1__ 4. Rounded protuberances on each side of the ankle

e. Malleolus __4__ 5. Small tarsal bone that sits toward the outside of the foot, in the midfoot area

ICD-10-CM Coding Workbook for Orthopaedics Answers and Rationales

© 2016 Optum360, LLC 175

3. If this patient had endured a nondisplaced navicular fracture in his foot, which ICD-10-CM diagnosis code would be reported?

a. S62.002A Unspecified fracture of navicular [scaphoid] bone of left wrist, initial encounter for closed fracture

b. S62.035A Nondisplaced fracture of proximal third of navicular [scaphoid] bone of left wrist,initial encounter for closed fracture

c. S92.255A Nondisplaced fracture of navicular [scaphoid] of left foot, initial encounter for closed fracture

d. S62.015A Nondisplaced fracture of distal pole of navicular [scaphoid] bone of left wrist, initialencounter for closed fracture

There is a navicular bone in the foot and the wrist, so it is important to be aware of which area is being treated and, therefore, being coded. In this instance, it is the navicular bone in the foot. A nondisplaced navicular fracture of the foot would be appropriately assigned to S92.255 with seventh character “A” representing the initial encounter.

4. What would be the appropriate additional external cause code if this injury came frombeing stepped on by one of the players on the other team?

W50.0XXA Accidental hit or strike by another person, initial encounter

If this injury was the result of the patient being stepped on by a player on the opposite team, there is an additional code that can be added to the current external cause codes already provided. Main term “Stepped on by” and subterm “person” in the Index to External Causes reference code W50.0. The tabular list indicates that seven characters are required for this code. Characters five and six are “X” placeholders. Character seven is an “A” to indicate the initial encounter for this injury. According to the ICD-10-CM Draft Official Guidelines for Coding and Reporting, Section I.C.20.a.4, it is appropriate to report as many external cause codes as necessary to completely explain the circumstances.

5. This patient returned for a follow-up visit three months later. He was having no further problems and seemed to be healthy, but given his role in athletics it was felt that he should have this routine follow-up visit. What is the appropriate first-listed ICD-10-CM diagnosis code for this visit?

a. Z02.5 Encounter for examination for participation in sport

b. Z47.89 Encounter for other orthopedic aftercare

c. S93.692D Other sprain of left foot, subsequent encounter

d. S93.692A Other sprain of left foot, initial encounter

Based on the information provided in the ICD-10-CM Draft Official Guidelines for Coding and Reporting, Section I.C.19.a, seventh character “D” is used to indicate subsequent encounters. A subsequent encounter is any encounter that occurs after the active phase of treatment has concluded for which the patient is receiving routine follow-up care. In this instance, the patient was returning three months after his initial treatment. Based on the information provided in the question above, there was no active care still ongoing. This visit was simply for a routine aftercarevisit to verify that the patient was still healing properly and could perform in athletics as needed.