Orthopaedic ICD-10 CM Training. ICD-10-CM will be valid for dates of service on or after October 1, 2015 – Outpatient dates of service of October 1, 2015

Orthopaedic

ICD-10 CM Training

• ICD-10-CM will be valid for dates of service on or after October 1, 2015– Outpatient dates of service of October 1, 2015 and

beyond. – Inpatient hospital service claims, is effective for dates of

discharge after September 30, 2015

ICD-10-CM Compliance Dates

• Covered Entities– Everyone covered by the Health Insurance Portability

Accountability Act (HIPPA)

• Non-Covered Entities– Worker’s Compensation– Auto Insurance– Non covered HIPAA entities are exempt but are

encouraged to adapt the new code set

Covered and Non-Covered Entities

• 21 Chapters• Alpha-numeric codes; not case-sensitive

– Codes begin with Alpha letter, A-Z, excluding U– Common errors

• I verses 1• O verses 0

• “X” Placeholder• 3 to 7 characters

– Decimal following 3rd character

ICD-10 Code Structure

• Placeholder “X”– Used for future expansion of a code– Fills in empty characters when a 6th and/or 7th character

apply– The placeholder may be used in different scenarios but

should never serve as the final character.

Example: W19.XXXA Unspecified fall, Initial Encounter


• 7th Character– Provides specified information regarding the clinical visit– Is required for certain categories and must be reported in

the seventh position– May be alpha or numeric– Has different meanings depending on the coding category


• Laterality– Some ICD-10-CM codes indicate laterality, specifying

whether the condition occurs on the left, right or is bilateral.

– If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.

– If the side is not identified in the medical record, assign the code for the unspecified side.

OGCR section 1.B.13


• “Other” Codes– Codes titled “other” or “other specified” are for use when

the information in the medical record provides detail for which a specific code does not exist.

• “Unspecified” Codes– Codes titled “unspecified” are for use when the

information in the medical record is insufficient to assign a more specific code.

OGCR section 1.A.9.a.b


• Excludes Notes– Excludes1

• A type 1 Excludes note is a pure excludes note• It means “NOT CODED HERE”• The code excluded should never be used at the same time• When two conditions cannot occur together

– Excludes2• Represents “Not included here”• The condition excluded is not part of the condition represented

by the code• It is acceptable to use both the code and the excluded code

together, when appropriateOGCR section 1.A.12.a.b

ICD-10 Structure

• “Code First” and “Use Additional Code”– ICD-10 has a coding convention that requires the

underlying condition be sequenced first followed by the manifestation.

– These instructional notes indicate the proper sequencing order of the codes.

OGCR section 1.A.13

• The “-” indicates there are additional reporting options


Most Common Diagnosis Codes

Pain of JointCategory M25.5 Excludes1 Excludes2

• Contracture of muscle without contracture of joint (M62.4-)

• Contracture of tendon (sheath) without contracture of joint (M62.4-)

• Dupuytren’s contracture (M72.0)

• acquired deformities of limbs (M20-M21)

Pain, ShoulderICD-9 Code ICD-10 Code Description

719.41 M25.511 Pain, right shoulder

719.41 M25.512 Pain, left shoulder

719.41 M25.519 Pain, unspecified shoulder

Pain, ElbowICD-9 Code ICD-10 Code Description

719.42 M25.521 Pain, right elbow

719.42 M25.522 Pain, left elbow

719.42 M25.529 Pain, unspecified elbow

Pain, WristICD-9 Code ICD-10 Code Description

719.43 M25.531 Pain, right wrist

719.43 M25.532 Pain, left wrist

719.43 M25.539 Pain, unspecified wrist

Pain, HipICD-9 Code ICD-10 Code Description

719.45 M25.551 Pain, right hip

719.45 M25.552 Pain, left hip

719.45 M25.559 Pain, unspecified hip

Pain, KneeICD-9 Code ICD-10 Code Description

719.46 M25.561 Pain, right knee

719.46 M25.562 Pain, left knee

719.46 M25.569 Pain, unspecified knee

Pain, Ankle and Foot ICD-9 Code ICD-10

CodeDescription

719.47 M25.571 Pain, right ankle and foot

719.47 M25.572 Pain, left ankle and foot

719.47 M25.579 Pain, unspecified ankle and foot

Pain, Unspecified Joint719.40719.48719.49

M25.50 Pain, unspecified joint

Documentation Tips• Site• Laterality

– Right– Left – Unspecified

• Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition.

Documentation Tips

Bone versus joint– For certain conditions, the bone may be affected

at the upper or lower end, (e.g., avascular necrosis of bone, M87, Osteoporosis, M80, M81). Though the portion of the bone affected may be at the joint, the site designation will be the bone, not the joint.

Osteoarthritis of kneeICD-9 Code ICD-10 Code Description Excludes1 Excludes2

715.96 M17.9 Osteoarthritis of knee, unspecified

N/A • osteoarthritis of spine (M47.-)

There are more specific code choice selections below:

M17.0 Bilateral primary osteoarthritis of knee

M17.10 Unilateral primary osteoarthritis, unspecified knee

M17.11 Unilateral primary osteoarthritis, right knee

M17.12 Unilateral primary osteoarthritis, left knee

M17.2 Bilateral post-traumatic osteoarthritis of knee

M17.30 Unilateral post-traumatic osteoarthritis, unspecified knee

M17.31 Unilateral post-traumatic osteoarthritis, right knee

M17.32 Unilateral post-traumatic osteoarthritis, left knee

M17.4 Other bilateral secondary osteoarthritis of knee

M17.5 Other unilateral secondary osteoarthritis of knee

Identify– Site – Laterality– Type

• Primary• Post-traumatic• Other secondary• Unspecified

Documentation Tips

Osteoarthritis of hipICD-9 Code ICD-10 Code Description Excludes1 Excludes2

715.95 M16.9 Osteoarthritis of hip, unspecified

• bilateral involvement of single joint (M16-M19)

• osteoarthritis of spine (M47.-)


M16.0 Bilateral primary osteoarthritis of hip

M16.10 Unilateral primary osteoarthritis, unspecified hip

M16.11 Unilateral primary osteoarthritis, right hip

M16.12 Unilateral primary osteoarthritis, left hip

M16.2 Bilateral osteoarthritis resulting from hip dysplasia

M16.30 Unilateral osteoarthritis resulting from hip dysplasia, unspecified hip

M16.31 Unilateral osteoarthritis resulting from hip dysplasia, right hip

M16.32 Unilateral osteoarthritis resulting from hip dysplasia, left hip

M16.4 Bilateral post-traumatic osteoarthritis of hip

M16.50 Unilateral post-traumatic osteoarthritis, unspecified hip

M16.51 Unilateral post-traumatic osteoarthritis, right hip

M16.52 Unilateral post-traumatic osteoarthritis, left hip

M16.6 Other bilateral secondary osteoarthritis of hip

M16.7 Other unilateral secondary osteoarthritis of hip

Identify:• LateralityBone versus joint• For certain conditions, the bone may be affected at

the upper or lower end, (e.g., avascular necrosis of bone, M87, Osteoporosis, M80, M81). Though the portion of the bone affected may be at the joint, the site designation will be the bone, not the joint.

Documentation Tips

Cardiac murmur, unspecifiedICD-9 Code ICD-10 Code Description Excludes1 Excludes2

726.13 M75.110 Incomplete rotator cuff tear or rupture of unspecified shoulder, not specified as traumatic

• Tear of rotator cuff, traumatic (S46.01-)

• Shoulder-hand syndrome (M89.0-)


M75.111 Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic

M75.112 Incomplete rotator cuff tear or rupture of left shoulder, not specified as traumatic

Note: Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition

Identify:• Laterality

Documentation Tips

Unspecified fracture of forearmICD-9 Code ICD-10 Code Description Excludes1 Excludes2

813.40 S52.90xA Unspecified fracture of unspecified forearm

• Traumatic amputation of forearm (S58.-)

• Fracture of wrist and hand level (S62.-)


S52.91x- Unspecified fracture of right forearm

S52.92x- Unspecified fracture of left forearm

The appropriate 7th character is to be added to all codes from category S52A - initial encounter for closed fractureB - initial encounter for open fracture type I or IIinitial encounter for open fracture NOSC - initial encounter for open fracture type IIIA, IIIB, or IIICD - subsequent encounter for closed fracture with routine healingE - subsequent encounter for open fracture type I or II with routine healingF - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healingG - subsequent encounter for closed fracture with delayed healingH - subsequent encounter for open fracture type I or II with delayed healingJ - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healingK - subsequent encounter for closed fracture with nonunionM - subsequent encounter for open fracture type I or II with nonunionN - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunionP - subsequent encounter for closed fracture with malunionQ - subsequent encounter for open fracture type I or II with malunionR - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunionS - sequela

• A fracture not indicated as open or closed should be coded to closed. A fracture not indicated whether displaced or not displaced should be coded to displaced.

• The open fracture designations are based on the Gustilo open fracture classification

• Identify:– Laterality

Documentation Tips

Low back painICD-9 Code ICD-10 Code Description Excludes1 Excludes2

724.2 M54.5 Low back pain

• Loin pain• Lumbago NOS

• psychogenic dorsalgia (F45.41)

• low back strain (S39.012)

• lumbago due to intervertebral disc displacement (M51.2-)

• lumbago with sciatica (M54.4-)

N/A

• Document site and laterality– Unspecified codes should be used only in rare

circumstances

• With or without sciatica• Use an external cause code following the code for

the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition.

Low Back Pain Documentation Tips

Trochanteric bursitisICD-9 Code ICD-10 Code Description Excludes1 Excludes2

726.5 M70.60 Trochanteric bursitis, unspecified hip

Applicable to:Trochanteric tendinitis

• bursitis NOS (M71.9-)

• bursitis of shoulder (M75.5)

• enthesopathies (M76-M77)

• pressure ulcer (pressure area) (L89.-)M70.70 Other bursitis of hip,

unspecified hipM76.10 Psoas tendinitis,

unspecified hipM76.20 Iliac crest spur, unspecified

hipThere are more specific code choice selections below:

M70.60 Trochanteric bursitis, unspecified hip

M70.61 Trochanteric bursitis, right hip

M70.62 Trochanteric bursitis, left hip

Identify:• laterality

Documentation Tips

Carpal tunnel syndrome, unspecified upper limbICD-9 Code ICD-10

CodeDescription Excludes1 Excludes2

354.0 G56.00 Carpal tunnel syndrome, unspecified upper limb

• current traumatic nerve disorder - see nerve injury by body region

N/A


G56.01 Carpal tunnel syndrome, right upper limb

G56.02 Carpal tunnel syndrome, leftt upper limb

Identify:• Laterality

Documentation Tips

Unspecified intracapsular fracture of femurICD-9 Code ICD-10 Code Description Excludes1 Excludes2

820.00 S72.019A Unspecified intracapsular fracture of femur

Applicable to:• Subcapital fracture of

femur

• traumatic amputation of hip and thigh (S78.-)

• fracture of lower leg and ankle (S82.-)

• fracture of foot (S92.-)• periprosthetic fracture of

prosthetic implant of hip (T84.040, T84.041)


S72.011- Unspecified intracapsular fracture of right femur

S72.012- Unspecified intracapsular fracture of left femur


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


• Identify:– Laterality– Open or closed

Documentation Tips

Pain in limbICD-9 Code ICD-10 Code Description Excludes1 Excludes2

729.5 M79.60- Pain in limb, unspecified • psychogenic rheumatism (F45.8)

• soft tissue pain, psychogenic (F45.41)

• Pain in joint (M25.5-)


729.5 M79.62- Pain in upper arm

729.5 M79.63- Pain in forearm

729.5 M79.64- Pain in hand and fingers

729.5 M79.65- Pain in thigh

729.5 M79.66- Pain in leg

729.5 M79.67- Pain in foot and toes

• Site• Laterality

• Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition

Documentation Tips

Sprain of unspecified rotator cuff capsuleICD-9 Code ICD-10 Code Description Excludes1 Excludes2

840.4 S43.429A Sprain of unspecified rotator cuff capsule, initial encounter

• rotator cuff syndrome (complete) (incomplete), not specified as traumatic (M75.1-)

• strain of muscle, fascia and tendon of shoulder and upper arm (S46.-)

• injury of tendon of rotator cuff (S46.0-)

840.4 S43.429D Sprain of unspecified rotator cuff capsule, subsequent encounter

840.4 S43.429S Sprain of unspecified rotator cuff capsule, sequela

Code also any associated open wound


S43.421- Sprain of right rotator cuff capsule

S43.422- Sprain of left rotator cuff capsule

S43.429- Sprain of unspecified rotator cuff capsule

• Use secondary code(s) from Chapter 20, External causes of morbidity, to indicate cause of injury. Codes within the T section that include the external cause do not require an additional external cause code

• The chapter uses the S-section for coding different types of injuries related to single body regions and the T-section to cover injuries to unspecified body regions as well as poisoning and certain other consequences of external causes.


Documentation Tips

Secondary osteoarthritis, shoulderICD-9 Code ICD-10 Code Description Excludes1 Excludes2

715.21 M19.219 Secondary osteoarthritis, unspecified shoulder

• Polyarthritis (M15.1-)

• arthrosis of spine (M47.-)

• Hallux rigidus (M20.2)• osteoarthritis of

spine (M47.-)There are more specific code choice selections below:

M19.211 Secondary osteoarthritis, right shoulder

M19.212 Secondary osteoarthritis, left shoulder

Identify:– Laterality– Primary, Secondary, Post-traumatic

Documentation Tips

Displaced intertrochanteric fracture of femurICD-9 Code ICD-10 Code Description Excludes1 Excludes2

820.21 S72.143- Displaced intertrochanteric fracture of unspecified femur

• traumatic amputation of hip and thigh (S78.-)

• fracture of lower leg and ankle (S82.-)

• fracture of foot (S92.-)• periprosthetic fracture of

prosthetic implant of hip (T84.040, T84.041)


S72.141- Displaced intertrochanteric fracture of right femur

S72.142- Displaced intertrochanteric fracture of left femur


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



Documentation Tips

Other specified postprocedural statesICD-9 Code ICD-10 Code Description Excludes1 Excludes2

V45.89 Z98.89 Other specified postprocedural states

Applicable To:• Personal history of

surgery, not elsewhere classified

N/A N/A

Code also any follow-up examination (Z08-Z09)

Note: Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is performed. Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y89 are recorded as 'diagnoses' or 'problems'. This can arise in two main ways:

(a) When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination (immunization), or to discuss a problem which is in itself not a disease or injury.(b) When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury.

Documentation Tips

On October 01, 2015 we will monitor claims for date of service rules

• Outpatient claims cannot have crossover dates • Outpatient claims will be coded according to date of

service• Inpatient facility claims will be coded per date of discharge

We will monitor claims to resolve any unanticipated problems with the submission process

Monitor Claims

• We will monitor for claim denials• We will monitor editing trends for ICD-10 Coding

guidelines• We will provide feedback to the physicians regarding

supporting documentation requirements • We will monitor WC or Liability carriers for published

rules on use of ICD-9 or ICD-10 code sets

Claim Denial and Management

• Client will need to update – Templates– Order Sets– Superbills– Favorites

• Future Orders– Remove ICD-9 code add ICD-10 code

Client Responsibilities

All Conditions treated or assessed must be documented in the medical record. In addition to the documentation tips reviewed, below are more areas to document that will ensure proper ICD-10-CM code selection.

• Site specificity• Document notation of qualifiers

– Exacerbation– Manifestations– Relapse– Status– Stages

• Indicate acute or chronic• Indicate underlying or external cause factors

– Medication– Smoke– Accidents– Mechanical failure

• Laterality– Bilateral– Right – Left

Documentation – Start Now

• Episode of Care for injuries, poisoning, external causes and other conditions– Initial Encounter

• Use while the patient is receiving active treatment of the condition– Active treatment includes surgical treatment, an emergency encounter, and

evaluation and treatment by a new physician

– Subsequent Encounter• Used on encounter after the patient has received active treatment of

the condition and is receiving routine care for the condition during the healing or recovery phase.

– Medication adjustments, aftercare, device adjustments, cast change

– Sequela• Used for complications or conditions that arise as a direct result of a

condition, late effect


• Combination codes that capture– Etiology and manifestation– Related conditions– Disease, injury or other medical condition and

complications– Disease or other medical conditions and common signs or

symptoms

• Add ICD-10 Codes to patient Problem List


[email protected]

Centers for Disease Control and Prevention (ICD-10-CM)http://www.cdc.gov/nchs/icd/icd10cm.htm

Questions

mailto:[email protected]

http://www.cdc.gov/nchs/icd/icd10cm.htm

http://www.cdc.gov/nchs/icd/icd10cm.htm

Documents

Orthopaedic ICD-10 CM Training. ICD-10-CM will be valid for dates of service on or after October 1, 2015 – Outpatient dates of service of October 1, 2015