orthopaedic icd-10 cm training. icd-10-cm will be valid for dates of service on or after october 1,...
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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
ICD-10 Code Structure
• 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
ICD-10 Code Structure
• 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
ICD-10 Code Structure
• “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
ICD-10 Code Structure
• 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
ICD-10 Code Structure
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.-)
There are more specific code choice selections below:
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-)
There are more specific code choice selections below:
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.-)
There are more specific code choice selections below:
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
There are more specific code choice selections below:
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)
There are more specific code choice selections below:
S72.011- Unspecified intracapsular fracture of right femur
S72.012- Unspecified intracapsular fracture of left femur
The appropriate 7th character is to be added to all codes from category S72A - 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
• The open fracture designations are based on the Gustilo open fracture classification
• 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-)
There are more specific code choice selections below:
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
There are more specific code choice selections below:
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.
• Identify:– Laterality
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)
There are more specific code choice selections below:
S72.141- Displaced intertrochanteric fracture of right femur
S72.142- Displaced intertrochanteric fracture of left femur
The appropriate 7th character is to be added to all codes from category S72A - 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
• The open fracture designations are based on the Gustilo open fracture classification
• Identify:– Laterality
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
Documentation – Start Now
• 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
Documentation – Start Now
Centers for Disease Control and Prevention (ICD-10-CM)http://www.cdc.gov/nchs/icd/icd10cm.htm
Questions