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ICD-10 Tutorials

Z codes:

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-Y89are recorded as 'diagnoses' or 'problems'. This can arise in two main ways:

  • 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.
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In the 2015 ICD In ICD-10-CM, the diagnosis code used for reporting administration of an immunization or vaccination is Z23, Encounter for immunization. Information on the specific immunization administered is provided by the procedure code.

For example, reporting code Z23 with CPT code 90655 would indicate that a split virus intramuscular influenza vaccine was administered to a child between 6 and 35 months of age.-10-CM draft, we still encounter that code Z23 applies to all vaccinations.

A 50-year-old patient presents for an office visit for ongoing monitoring and evaluation of her diabetes and, during the same visit, Fluvirin (influenza vaccine) is administered. The physician might report code 99213-25 with diagnosis code E11.9 Type II diabetes without complications.* In addition, she/he would also report Z23 encounter for immunization and the appropriate flu vaccine 90656 and administration 90471 codes.

Revenue Codes:

0636 for the vaccine
0771 for the administration

*Annual Part B deductible and coinsurance amounts do not apply. All physicians, nonphysician practitioners, and suppliers who administer the influenza virus vaccination and the pneumococcal vaccination must take assignment on the claim for the vaccine- MLN matters-1523-CMS

"Code Z23 is for encounters for inoculations and vaccinations. It indicates that a patient is being seen to receive a prophylactic inoculation against a disease. Procedure codes are required to identify the actual administration of the injection and the type(s) of immunizations given. Code Z23 may be used as a secondary code if the inoculation is given as a routine part of preventive health care, such as a well-baby visit."

In ICD-10-CM, code Z23 contains a note that states, "Procedure codes are required to identify the types of immunizations given."

This code-Z23 is used for the description synonyms below:

  • Bacterial disease vaccination given
  • Bacterial disease vaccination given (situation)
  • Diphtheria and tetanus vaccination given
  • Diphtheria and tetanus vaccination given (situation)
  • Diphtheria, tetanus and acellular pertussis vaccination given
  • Diphtheria, tetanus and acellular pertussis vaccination given (situation)
  • Diphtheria, tetanus, acellular pertussis, haemophilus influenzae B and inactivated polio vaccinations given
  • Diphtheria, tetanus, acellular pertussis, haemophilus influenzae B and inactivated polio vaccinations given (situation)
  • Diphtheria, tetanus, acellular pertussis, hepatitis B and inactivated polio vaccinations given
  • Diphtheria, tetanus, acellular pertussis, hepatitis B and inactivated polio vaccinations given (situation)
  • Diphtheria, tetanus, pertussis and polio vaccination given
  • Diphtheria, tetanus, pertussis and polio vaccination given (situation)
  • Haemophilus influenzae type b vaccination
  • Haemophilus influenzae type b vaccination (procedure)
  • Herpes zoster vaccination given
  • Herpes zoster vaccination given (situation)
  • Human papilloma virus vaccination given
  • Human papilloma virus vaccination given (situation)
  • Influenza vaccination given
  • Influenza vaccination given (situation)
  • Measles, mumps and rubella vaccination given
  • Measles, mumps and rubella vaccination given (situation)
  • Meningococcal vaccination given
  • Meningococcal vaccination given (situation)
  • Pneumococcal 13-valent conjugate vaccination given
  • Pneumococcal 13-valent conjugate vaccination given (situation)
  • Pneumococcal 23-valent polysaccharide vaccination given
  • Pneumococcal 23-valent polysaccharide vaccination given (situation)
  • Vaccination for bacterial disease
  • Vaccination for diphtheria, tetanus and acellular pertussis
  • Vaccination for diphtheria, tetanus and acellular pertussis (DTaP)
  • Vaccination for diphtheria, tetanus, acellular pertussis, haemophilus influenzae type B and polio
  • Vaccination for diphtheria, tetanus, pertussis, and polio
  • Vaccination for haemophilus influenzae type B
  • Vaccination for herpes zoster
  • Vaccination for HPV
  • Vaccination for human papilloma virus (HPV)
  • Vaccination for influenza
  • Vaccination for measles, mumps and rubella
  • Vaccination for measles, mumps and rubella (MMR)
  • Vaccination for meningococcus
  • Vaccination for strep pneumonia w pneumovax
  • Vaccination for strep pneumonia w Prevnar 13
  • Vaccination for Streptococcus pneumoniae with pneumovax
  • Vaccination for Streptococcus pneumoniae with Prevnar 13
  • Vaccination for tetanus and diphtheria
  • Vaccination for tetanus, diphtheria, acellular pertussis, hepatitis B and polio
  • Vaccination for varicella
  • Vaccination for varicella (chicken pox)
  • Vaccination for viral hepatitis
  • Vaccination for yellow fever
  • Vaccination w combination vaccine
  • Vaccination with combination vaccine
  • Vaccination with combination vaccine done
  • Vaccination with combination vaccine done (situation)
  • Varicella vaccination
  • Varicella vaccination (procedure)
  • Viral hepatitis vaccination given
  • Viral hepatitis vaccination given (situation)
  • Yellow fever vaccination given
  • Yellow fever vaccination given (situation)

For components: visit this site

https://www.aap.org/en-us/professional-resources/practice-support/Coding-at-the-AAP/Documents/Vaccine%20Coding%20Table.pdf

Burns Coding-ICD-10-CM

The impact that ICD-10 is going to create by its implementation may be probably more than what is perceived by majority of healthcare professionals. Assumptions that a training of 15 days, or 4weeks will suffice for the preparedness, may prove dangerous.

Many coding scenarios for which a seasoned coder is habitual for assigning codes may put them in chaos. Coding of burns is such a situation. Even though the basic definitions of the degrees of burn injuries are not changed but there is change in the axis of classification and laterality that could make the work difficult to low smoothly.

ICD-10-CM burn and corrosion injury codes are classified by depth, extent and by the agent causing burn injury. Classification based on the depth of the burn injury includes first degree (erythema), second degree (blistering), and third degree (full-thickness involvement). Burns and corrosions of the eye and adnexa and internal organs are classified by site not by the degree and extent.

ICD-9-CM codes do not differentiate between chemical burns and burns caused by hot objects, fire, lightning, electric burns. All burn injuries are coded in ICD-9 with the same group of codes, except sunburns and friction burns. But ICD-10-CM distinguishes burns caused by chemicals with thermal burns (burns that come from a heat source). So thermal burns caused by electrical appliances, flame, hot gas, liquid or hot object, radiation, steam, radiation and friction burns are coded with one group of codes whereas burns caused by chemicals i.e., corrosions are coded with separate group of codes in the same category. The coding guidelines for thermal burns and corrosions are same with some exceptions.

A burn injury code for thermal burn can be differentiated with that of the corrosion burn injury code by looking on the fourth digit in the code i.e. the first digit after the decimal point (TXX.X). If the fourth the digit in the burn injury code is any number from 0-3 the code is for thermal burn injury whereas, if the fourth digit in the code is any number beyond 3, then the code is for corrosion burns.

All the burn injury codes for specified sites should have a 7th character extension to indicate the encounter as initial or subsequent etc. Seventh character "A" is assigned for initial treatment or "D" for subsequent care and "S" for the management of a sequela. In case of encounter related with the treatment of a scar or joint contracture developed as a result of a burn injury, the 7th character extension "S" is applied to the injury codes to indicate that it is a late-effect or sequela of the injury.

There are no separate codes in the ICD-10-CM for the late-effects of burn injuries. Similar to the other injury codes, the burn injury code is assigned with 7th character "S" for the late-effects. However the condition or nature of late-effect code eg. Scar should also be coded along with the injury code with the 7th character extension "S" (to the injury code only) that resulted in the development of sequela. The code for the condition or nature of late-effect should be sequenced first, and the seventh character extension "S" should not be added to the code for the condition or nature of late-effect.

In ICD-9-CM there are codes for burn injuries which are deep third degree without loss of body part or with loss of body part, but there are no such burn injury codes in ICD-10-CM.

Except burns for eye and adnexa(T26), respiratory tract(T27) and other internal organs(T28), current burns are classified in the categories T20-T25. Burns of the eye and internal organs (T26-T28) are classified by site, but not by degree.

Except burns for eye and adnexa(T26), respiratory tract(T27) and other internal organs(T28), current burns are classified in the categories T20-T25. Burns of the eye and internal organs (T26-T28) are classified by site, but not by degree.

Category T30 codes are extremely vague. A code from this category should be very rarely used, as a last resort when no information about the site of burn or corrosion is available.

Codes in category T31 and T32 are classified according to the extent of the body surface involved in the burn(T31) or corrosion(T32) injury. Codes from T31 and T32 are to be used as the primary code only when the site of burn or corrosion is unspecified. They should also be used as additional codes with codes from category T20-T25 when the site is specified.

To all the burn injury codes in categories T20-T28, additional external cause codes to identify the source, place and intent of the burn from (X00-X19, X75-X77, X96-X98, Y92) should also be added.

While assigning corrosion injury codes in categories T20-T28, a code from T51-T65 should be assigned first to identify the chemical and intent followed by a code from T20-T28. An additional external cause code to identify the place from category Y92 should also be added to the corrosion injury codes.

Coding guidelines for coding of burn injuries:

  • Sequence the first code that reflects the highest degree of burn when more than one burn is present.
  • When the reason for the admission or encounter is for treatment of external multiple burns, sequence first the code that reflects the burn of the highest degree.
  • When a patient has both internal and external burns, the circumstances of admission govern the selection of the principal diagnosis or first-listed diagnosis.
  • When a patient is admitted for burn injuries and other related conditions such as smoke inhalation and/or respiratory failure, the circumstances of admission govern the selection of the principal or first-listed diagnosis.
  • Classify burns of the same local site (three-digit category level, T20-T28) but of different degrees to the subcategory identifying the highest degree recorded in the diagnosis.
  • Non-healing burns are coded as acute burns. Necrosis of burned skin should be coded as a non-healed burn.
  • For any documented infected burn site, use an additional code for the infection.
  • When coding burns, assign separate codes for each burn site. Category T30, Burn and corrosion, body region unspecified is extremely vague and should rarely be used.
  • Assign codes from category T31, Burns classified according to extent of body surface involved, or T32, Corrosions classified according to extent of body surface involved, when the site of the burn is not specified or when there is a need for additional data. It is advisable to use category T31 as additional coding when needed to provide data for evaluating burn mortality, such as that needed by burn units. It is also advisable to use category T31 as an additional code for reporting purposes when there is mention of a third-degree burn involving 20 percent or more of the body surface. Categories T31 and T32 are based on the classic "rule of nines" in estimating body surface involved: head and neck are assigned nine percent, each arm nine percent, each leg 18 percent, the anterior trunk 18 percent, posterior trunk 18 percent, and genitalia one percent. Providers may change these percentage assignments where necessary to accommodate infants and children who have proportionately larger heads than adults, and patients who have large buttocks, thighs, or abdomen that involve burns.
  • Encounters for the treatment of the late effects of burns or corrosions (i.e., scars or joint contractures) should be coded with a burn or corrosion code with the 7th character "S" or sequela.
  • When appropriate, both a code for a current burn or corrosion with 7th character extension "A" or "D" and a burn or corrosion code with extension "S" may be assigned on the same record (when both a current burn and sequelae of an old burn exist). Burns and corrosions do not heal at the same rate and a current healing wound may still exist with sequela of a healed burn or corrosion.
  • An external cause code should be used with burns and corrosions to identify the source and intent of the burn, as well as the place where it occurred.

It is obvious that the guidelines, alphanumeric structure of the codes, laterality, 7th character extensions, code first and additional code requirements are to be given the required attention while assigning burn injury codes in the ICD-10-CM. The transition can never be underestimated as less than a challenge.

HIV Coding-ICD-10-CM

HIV Coding Under ICD-10

I.C.1.a.1. HIV Infections - Code only confirmed cases

Note that this is an exception to the hospital inpatient guidelines Section II.H.

This guideline instructs us to code only confirmed cases of HIV infection/illness. The guideline does not require documentation of a positive serology or culture for HIV within the encounter. However, a provider's diagnostic statement is needed as confirmation.

"Confirmation" does not require documentation of positive serology or culture for HIV; the physician's diagnostic statement that the patient is HIV positive, or has an HIV-related illness is sufficient

Example: Diagnostic statements may include that the patient is HIV positive (with documented symptoms), or the patient has an HIV-related illness, or AIDS, or ARC.

Note: Code B20 Human immunodeficiency virus (HIV) disease includes:

Acquired immune deficiency syndrome (AIDS), AIDS-related complex (ARC), HIV infection, symptomatic.

Does GEM files really helps:

Let us see an example:

Z21, Asymptomatic human immunodeficiency virus [HIV] infection status, is to be applied when the patient without any documentation of symptoms is listed as being "HIV positive," "known HIV," "HIV test positive," or similar terminology.

Now analyse the GEM files:

ICD-9 to ICD-10 GEM

V08 is Mapped to the Z21. (Exact Match)

Compare the ICD-10-ICD-9-GEM

V08 is mapped to Z22.6: Z22.6 Carrier of human T-lymphotropic virus type-1 [HTLV-1] infection.

Z11.4: Encounter for screening for human immunodeficiency virus [HIV] is very specific compared to the code V73.8: Special screening examination for other specified viral diseases.

There is one more code for the carrier:

Z22.6: Carrier of human T-lymphotropic virus type-1 [HTLV-1] infection

  • To use these codes correctly, the physician must provide complete information about the manifestations of the HIV-related illnesses and their relationship to HIV. Coders should not assume that conditions are HIV related unless the physician so indicates.
  • All manifestations of HIV infection must be coded.
  • Selection of the principal diagnosis should be based on the information contained in the individual patient record. The B20 code should be listed as the principal diagnosis when a patient is admitted to a health-care facility for an HIV-related condition. Additional codes for all HIV- related conditions should be assigned as other diagnoses.
  • A patient with HIV disease may be admitted to a health-care facility for an unrelated condition. In these cases, the unrelated condition should be the principal diagnosis, with the B20 code listed as an additional diagnosis, followed by the codes for the manifestations of the HIV disease.
  • Asymptomatic HIV infection should be coded as Z21 and not as B20. However, patients who have a history of symptomatic HIV infection, but who are currently asymptomatic, should be coded as B20.
  • Use additional code to identify HIV-2 infection B97.35 if present.
Example:

HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old man with the AIDS complicated with recent cryptococcal infection, Kaposi's sarcoma. His viral load in July of 2008 was 244,000 and CD4 count was 11. He was recently admitted for debility and possible pneumonia. He was started on antiretroviral therapy, was also found to have pleural effusion on the right. He has overall weakness.

PAST MEDICAL HISTORY: Unremarkable.

MEDICATIONS: Acetaminophen 650 mg q.6h. p.r.n. fever, which he has not been using, Motrin 400 mg q.6h. p.r.n. pain, which has not helped. His pain and dexamethasone with guaifenesin 5-10 mL q.4h. p.r.n. cough.

ALLERGIES: He has no known allergies.

SOCIAL HISTORY: The patient is now staying with his mother. He is the youngest of six children

PHYSICAL EXAMINATION: Blood pressure 135/80, pulse 110, and respirations 27. Temperature 102.9. General Appearance: Ill-looking young man, diaphoretic. PERRLA, 3 mm. Oral mucosa moist without lesions. Lungs: Diminished breath sounds in the right middle lower lobe. Heart: RRR without murmurs. Abdomen: Distended with soft and nontender. Diminished bowel sounds. Extremities: Without cyanosis or edema. There is a large Kaposi's sarcoma on the right medial leg and left medial proximal thigh, which is somewhat tender. Neurological Exam: Cranial nerves II through XII are grossly intact. There is normal tone. Power is 4/5. DTRs nonreactive. Normal fine touch. Mental Status: The patient is somnolent, but arousable. Withdrawn affect. Normal speech and though process.

ASSESSMENT AND PLAN:

  • AIDS complicated with multiple opportunistic infections with poor performance status, which suggested a limited prognosis of less than six months. He will benefit from home hospice care and he declined any further antibiotic or antiretroviral treatments.
  • Cough. We will use oxycodone with the same indication as well.
  • Fever. We encouraged him to use Tylenol as needed.
  • Insomnia. We will use lorazepam 0.25-0.5 mg at bedtime as needed.
  • Psychosocial. We discussed his coping with the diagnosis. He is fully aware of his limited prognosis. Supportive counseling was provided to his mother.

ICD-10 Codes: B20, R05, R50.9, G47.01

Acute Respiratory Failure

Definition: The term respiratory failure, in medicine, is used to describe inadequate gas exchange by the respiratory system, with the result that arterial oxygen and/or carbon dioxide levels cannot be maintained within their normal ranges. A drop in blood oxygenation is known as hypoxemia; a rise in arterial carbon dioxide levels is called hypercapnia. The normal reference values are: oxygenPaO2 greater than 80 mmHg (11 kPa), and carbon dioxide PaCO2 less than 45 mmHg (6.0 kPa). Classification into type I or type II relates to the absence or presence of hypercapnia respectively.

Code J96.0, Acute respiratory failure, or code J96.2, Acute and chronic respiratory failure or Acute on chronic respiratory failure, may be assigned as a principal diagnosis when it meets the principal diagnosis criteria. The selection must also be supported by the Alphabetic Index and Tabular List. In order to correctly sequence respiratory failure, documentation must be reviewed for present on admission indicators as well.

  • Acute respiratory failure as principal diagnosis
  • Code J96.0, Acute respiratory failure, or code J96.2, Acute and chronic respiratory failure, may be assigned as a principal diagnosis when it is the condition established after study to be chiefly responsible for occasioning the admission to the hospital, and the selection is supported by the Alphabetic Index and Tabular List. However, chapter-specific coding guidelines (such as obstetrics, poisoning, HIV, newborn) that provide sequencing direction take precedence.

Acute respiratory failure as secondary diagnosis

Respiratory failure may be listed as a secondary diagnosis if it occurs after admission, or if it is present on admission, but does not meet the definition of principal diagnosis.

Sequencing of acute respiratory failure and another acute condition

When a patient is admitted with respiratory failure and another acute condition, (example; myocardial infarction, cerebrovascular accident, aspiration pneumonia), the principal diagnosis will not be the same in every situation. This applies whether the other acute condition is a respiratory or non-respiratory condition. Selection of the principal diagnosis will be dependent on the circumstances of admission. If both the respiratory failure and the other acute condition are equally responsible for occasioning the admission to the hospital, and there are no chapter-specific sequencing rules, the guideline regarding two or more diagnoses that equally meet the definition for principal diagnosis (Section II, C.) may be applied in these situations.

If the documentation is not clear as to whether acute respiratory failure and another condition are equally responsible for occasioning the admission, query the provider the clarification.

A type 1 Excludes note is a pure excludes note. It means "NOT CODED HERE!" An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition.

Acute MI-ICD-10-CM Coding

The transition from ICD-9 to ICD-10 is expected to bring more accuracy in coding, precise reporting of diagnoses, more data granularity, and better data outcome for research purpose on one hand but, there are other factors that will haunt the work flow. One of those is the number of codes required to code a condition. Some of the conditions that were coded with only one code in ICD-9-CM may be reported with more than one code. Ultimately, the average time required to code a medical record is expected to increase by an average 50% or more per code. Coding of Acute Myocardial Infarction is one such example.

The difference in the guidelines of Acute Myocardial Infarction coding in ICD-9-CM and ICD-10-CM are to be carefully understood and coding with ICD-10-CM should be thoroughly practiced by the coders well before the deadline.

Even though the basis of categories of AMI in both ICD-9-CM and ICD-10-CM are same such as categories in both identify the site of the infarction such as anterolateral wall or true posterior wall, etc., but there are changes in the guidelines. The habit of using ICD-9-CM guidelines is to be stopped suddenly from October 1, 2013.

As per the ICD-9-CM guidelines, an Acute Myocardial Infarction is considered as acute until the duration of eight weeks with the difference of episodes of care as initial or subsequent at 5th digit level, whereas the ICD-10-CM considers an Acute Myocardial Infarction as acute until 28 days or less. There are new code categories i.e., subsequent Acute Myocardial Infarctions I22 for Myocardial Infarctions which occur after an initial AMI during the first 28 days.

ICD-10-CM category I21 is used for assigning codes to all the initial Acute Myocardial Infarction episodes both STEMI and NSTEMI. All the codes in I21 except I21.4 are assigned for STEMIs. Axis of the STEMI codes in I21 at fourth position identifies the site and 5th position identifies the coronary artery involved.

The category I22 codes are assigned to code the subsequent episodes of Myocardial Infarction. Except the code I22.2 (for subsequent NSTEMI), all other codes in the category I22 will be used to code subsequent STEMI encounters.

ICD-10-CM also provides category I23 for coding of complications of AMI (both STEMI and NSTEMI) if occurred within 28 days of an AMI initial or subsequent such as hemopericardium, rupture of cardiac wall, postinfarction angina, etc.

Additional Coding Requirements:

In ICD-9-CM, only one additional coding instruction for coding hypertension, if present, is an instructional note with Myocardial Infarction codes in category 410.

In ICD-10-CM codes, additional codes are required to code for different forms of tobacco use, dependence or history of tobacco use, status post rTPA (recombinant tissue plasminogen activator) administration in another facility in and body mass index.

Coding Guidelines:
  • When the patient requires continued care for the Myocardial Infarction, codes from category I21 may continue to be reported for the duration of 4 weeks (28 days) or less from onset, regardless of the healthcare setting, including when a patient is transferred from the acute care setting to the post-acute care setting if the patient is still within the four weeks time frame. For encounters after the 4 weeks' timeframe and the patient requires continued care related to the Myocardial Infarction, the appropriate aftercare code should be assigned, rather than a code from category I21. Otherwise, code I25.2, old Myocardial Infarction, may be assigned for old or healed Myocardial Infarction not requiring further care. (Note: This is an important difference in the guideline in comparison to ICD-9-CM)
  • A code from category I22, subsequent ST elevation (STEMI) and non ST elevation (NSTEMI) Myocardial Infarction, is to be used when a patient who has suffered an AMI has a new AMI within the 4 week time frame of the initial AMI. A code from category I22 must be used in conjunction with a code from category I21. The sequencing of the I22 and I21 codes depends on the circumstances of the encounter. Should a patient who is in the hospital due to an AMI have a subsequent AMI while still in the hospital code I21 would be sequenced first as the reason for admission, with a code from I22 sequenced as a secondary code. Should a patient have a subsequent AMI after discharge for care of an initial AMI, and the reason for admission is the subsequent AMI, the I22 code should be sequenced first followed by the I21. An I21 code must accompany an I22 code to identify the site of the initial AMI, and to indicate that the patient is still within the 4 week time frame of healing from the initial AMI. (A new guideline)
  • A code from category I23 must be used in conjunction with a code from category I21 or category I22. The I23 code should be sequenced first, if it is the reason for encounter, or, it should be sequenced after a code from I21 or I22 if the complication of the MI occurs during the encounter for the MI.
Documentation Requirements:
  • A precise diagnostic statement with clinical findings such as STEMI or NSTEMI
  • Documentation of the site of infarction
  • Description regarding the related coronary artery involved
  • Documentation about the AMI as initial or Subsequent
Coding Tips:
  • Follow the alphabetic index carefully then refer tabular list
  • Search the description of MI as STEMI or NSTEMI in the medical record
  • Identify the affected site and artery involved
  • Determine the episode to be coded as initial MI or subsequent MI
  • If Initial MI and Subsequent MI both present simultaneously follow the sequencing guidelines
Interesting Fact about ICD-10-CM Codes of Myocardial Infarction:

The term "Acute" is not use in defining the Myocardial Infarction category codes. The term acute is made as a non-essential modifier in the alphabetic index. It means that the ICD-10-CM doesn't identify myocardial infarction as "Acute" when there is no chronic existing.

It is evident that a determined effort is must to learn and achieve perfection, accuracy, and expertise in coding, and required documentation for a successful transition. A systematic approach towards the transition is the need of the hour.

Osteoarthritis ICD-10-CM Coding

Osteoarthritis, also known as degenerative arthritis or degenerative joint disease, is a group of mechanical abnormalities involving degradation of joints, including articular cartilage and subchondral bone. Symptoms may include joint pain, tenderness, stiffness, locking, and sometimes an effusion. A variety of causes; such as hereditary, developmental, metabolic, and mechanical may initiate processes leading to loss of cartilage. When bone surfaces become less well protected by cartilage, bone may be exposed and damaged. As a result of decreased movement secondary to pain, regional muscles may atrophy, and ligaments may become more lax. Mechanical stress is suggested as the most common cause for OA, but overweight, loss of strength in the muscles supporting the joint, are also suggested as the among the other common causes of OA.

The disease may commonly affect the hands, feet, spine, and the weight bearing joints such as hip, and knee, but any joint of the body may be affected.

Basically osteoarthritis is divided into primary and secondary depending upon whether or not there is an associated underlying cause.

Primary osteoarthritis develops as a result of a degenerative process in joint cartilage due to aging. Whereas, secondary OA may result from a variety of underlying factors such as diabetes, congenital diseases of joint, inflammatory or metabolic diseases such as rheumatoid arthritis and gout, injury to joints, septic arthritis, obesity etc.

Coding in ICD-10-CM for osteoarthritis is somewhat similar and also different to ICD-9-CM. ICD-9-CM provides category 715 for coding of osteoarthritis including degenerative, hypertrophic and secondary to other factors with the fourth digit determines the type as OA generalized(0), OA localized primary(1), OA localized secondary(2), OA localized not specified as primary or secondary(3), OA more than one site but not specified as generalized(8), and OA unspecified as generalized or localized(9). The fifth digit in category identifies the site of OA without regard to the laterality.

ICD-10-CM provides codes for the coding osteoarthritis related encounters in the categories M15-M19. The first category M15 is used to assign the codes for generalized forms of osteoarthritis or arthritis where multiple joints are involved.

ICD-10-CM codes for localized forms of osteoarthritis are classified in much detail specificity than that of its predecessor. ICD-10-CM has reserved three categories M16-M18 for the more common form of localized osteoarthritis i.e., M16, OA of hip, M17, OA of knee and M18, OA of first carpometacarpal joint. In these categories the:

fourth digit "0" identifies the OA as bilateral primary

  • fourth digit "0" identifies the OA as bilateral primary
  • fourth digit "1" identifies the OA as unilateral primary
  • fourth digit "2" "3" "4" "5" "6" or "7" identifies the different forms of secondary OA(due to dysplasia/post-traumatic) of hip, knee and carpometacarpal joint

The fifth digit in the categories M16-M18 further specifies the laterality into unspecified, right, and left sided joint of the body.

ICD-10-CM category M19 is used for coding primary or secondary osteoarthritis of all the joints other than hip, knee and first carpometacarpal joint. Codes in this category are identified with:

  • Fourth digit "0" identifies the OA as primary of other joints
  • Fourth digit "1" and "2" as for post-traumatic and secondary respectively

The fifth digit in the category M19 identifies the different joints of the body and the sixth digit specifies the laterality as into unspecified joint, right, left sided joint.

Coding tips:
  • Read the document carefully to identify the type of arthritis
  • Check the joint(s) involved
  • Determine the sub types of OA as primary or secondary
  • Assign the code as specific as possible by choosing the code for the correct laterality

Documentation guidelines:

From a provider, expectations are much more than a simple abbreviated diagnosis "OA" or "arthropathy" from them in ICD-10-CM environment. There is a need to stress on making the habit of

  • Describing the diagnostic statement in a more meaningful order
  • Document the type and subtype of the osteoarthritis with site(s) involved
  • Of course laterality is one of the major issues in ICD-10-Coding, better if described clearly the joint affected with the side involved such as bilateral, right or left.

Interesting Fact About ICD-10-CM

There are some instances where ICD-9-CM is much more specific than ICD-10-CM. Codes for unspecified arthropathies are more specific in ICD-9-CM than in ICD-10-CM. The reverse GEM of ICD-10-CM code M12.9 matches to ten (codes) possibilities in the subcategory 716.9 of ICD-9-CM.

Coding Fractures ICD-10

Coding of fractures in ICD-10-CM is quite cumbersome. A great deal of patience, with ICD-10 related knowledge of medical terminology, attentive attitude is required with proper training and practice to achieve necessary expertise in ICD-10-CM.

A lot is going to be changed in coding of fractures in ICD-10-CM. The organization of the alphabetic index the number of required digits for a code and the episode for visit are some of the important ones. In fact, the documentation requirements for coding of fractures or its related visits to a healthcare facility are also a whole lot different.

In ICD-9-CM, all the traumatic fractures were classified between categories 800-829 at one place in the chapter injury and poisoning, because the classification of injuries in ICD-9-CM is based on the type of injury. But in ICD-10-CM, the codes for the injuries are arranged by the body part rather than by type of the injury. For example, all injuries to the elbow and forearm are classified between categories S50-S59 that includes contusions, superficial injuries, open wounds, insect bites, fractures, dislocations and sprains, crushing injuries, etc. So the coder would be referring a different code range in the ICD-10-CM each time he searches a code for a different body part fracture.

The most interesting feature in all the fracture codes in ICD-10-CM is that all the codes should have a 7th character extension. The 7th character extensions are required for the fracture codes to add different type of information related to encounter. They must be assigned to all the fracture codes at seventh character position only, even if a fracture code is not of length of 6 characters by using place holder "X" in between.

It is obvious that we can add a wealth of information to the fracture codes in ICD-10-CM using the 7th character extensions.

Following here is a sample list of seventh character extension to be added to the category S82:

A - initial encounter for closed fracture

B - initial encounter for open fracture type I or II initial encounter for open fracture NOS

C - initial encounter for open fracture type IIIA, IIIB, or IIIC

D - subsequent encounter for closed fracture with routine healing

E - subsequent encounter for open fracture type I or II with routine healing

F - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing

G - subsequent encounter for closed fracture with delayed healing

H - subsequent encounter for open fracture type I or II with delayed healing

J - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing

K - subsequent encounter for closed fracture with nonunion

M - subsequent encounter for open fracture type I or II with nonunion

N - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion

P - subsequent encounter for closed fracture with malunion

Q - subsequent encounter for open fracture type I or II with malunion

R - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion

S -sequela

Each of the above 7th character adds specific meaning related to the encounter to the codes. This has eliminated the use of some additional codes related to aftercare or late-effect. The above 7th character extensions can be used as follows

  • Traumatic fractures are coded using the appropriate 7th character extension for initial encounter (A, B, C) Ex. of active treatment includes surgical treatment, emergency department encounter, and evaluation and treatment by a new physician
  • Fractures are coded using the appropriate 7th character extension for subsequent care for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase. Examples of fracture aftercare are: cast change or removal, removal of external or internal fixation device, medication adjustment, and follow-up visits following fracture treatment.
    • After care visits for routine healing fractures are coded with seventh character extensions (D, E, F)
    • After care visits for delayed healing fractures are coded with seventh character extensions (G, H, J)
  • Care of complications of fractures, such as malunionor nonunion, should be reported with the appropriate 7th character extensions for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R)

An advantage of these seventh character extensions in ICD-10-CM is that they indicate to the payer about the details of an encounter (initial encounter, follow up) with the specific type of injury (open fracture, closed fracture) and the progress (routine healing, delayed healing, malunion, nonunion), etc. It will also provide an understanding to the type of injury in case of late effects. The injury code when assigned with seventh character extension "S" it explains the type of injury resulting in the present late effect.

Important Guidelines:
  • 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
Additional Notes or Guidelines:
  • The aftercare Z codes should not be used for aftercare for traumatic fractures
  • Pathological fractures due to osteoporosis are coded in category M80
  • Pathological fractures not elsewhere classified are coded in category M84.4
  • Pathological fractures due to neoplasms are coded in category M84.5
  • Pathological fractures due to other diseases are coded in category M84.6
  • Care for complication of fractures, such as malunion and nonunion should be reported with appropriate 7th character extensions such as K,M,N,P,Q,R
  • Care for complications of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes

A coding example related to fracture in ICD-10-CM using seventh character extension "K":

Sam came to his physician's office with complaint of pain in left ankle, medial aspect after 2 months of active treatment for non-displaced medial malleolar fracture, closed. The imaging studies confirmed the pain is due to nonunion of fracture.

Code: S82.55XK, Nondisplaced fracture of medial malleolus of left tibia, subsequent encounter for closed fracture with nonunion

The above example is coded with seventh character extension "K" since the encounter is a subsequent one and the fracture is complicated by nonunion

Documentation Requirements:

Physicians must ensure the following documentation requirements to assist in seamless processing of claims.

  • Fracture type and location with laterality
  • Open or closed
  • Encounter details (initial/subsequent)
  • Late effects
  • Complications (malunion/nonunion)
Coding Tips:
  • The chapter specific important guidelines and must be adhered to
  • All codes in "S" series of ICD-10-CM with third character "2" are for different traumatic fractures, and S49, S59, S79, S89 are also used to code physeal fractures
  • Locate all the information in medical record about the fracture/location/type/laterality
  • Be attentive while assigning the 7th character extensions appropriately

Email drg@medesun.com if you have any questions..

Dr. Santosh Kumar Guptha
CCS-P, CCS , CPC, COC, CIC, CPC-P, CRC, CCC, CPCO, CANPC, CPB, CPMA, CEMC, CEDC, CIMC, CFPC, CUC, COBGC, CPCD, COSC, CPRC, CPEDC, CHONC, CENTC, CRHC, CGIC, CASCC, CGSC, CSFAC, CCVTC, RMC, RMA, CMBS, CMRS, CSCS, CSBB, FCR, FNR, FOR, CHA, CHL7, AHIMA Approved ICD-10 Trainer, AHIMA ICD-10 Ambassador, India.

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