ICD-10 CM Training
Orthopaedic
ICD-10-CM Compliance Dates
• 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
Covered and Non-Covered Entities
• 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
ICD-10 Code Structure
• 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 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 appropriate
OGCR section 1.A.12.a.b
ICD-10 Code 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 Joint
Category 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, Shoulder
Pain, Hip
ICD-9 Code
ICD-10 Code
Description
ICD-9 Code
ICD-10 Code
Description
719.41
M25.511
Pain, right shoulder
719.45
M25.551
Pain, right hip
719.41
M25.512
Pain, left shoulder
719.45
M25.552
Pain, left hip
719.41
M25.519
Pain, unspecified shoulder
719.45
M25.559
Pain, unspecified hip
Pain, Elbow
Pain, Knee
ICD-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, Wrist
ICD-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
ICD-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
Code
Description
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 Joint
719.40
719.48
719.49
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 knee
ICD-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
Documentation Tips
Identify
– Site
– Laterality
– Type
•
•
•
•
Primary
Post-traumatic
Other secondary
Unspecified
Osteoarthritis of hip
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
715.95
M16.9
Osteoarthritis of hip,
unspecified
•
•
bilateral
involvement of
single joint (M16M19)
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
Documentation Tips
Identify:
• Laterality
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.
Cardiac murmur, unspecified
ICD-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
Documentation Tips
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
Unspecified fracture of forearm
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
813.40
S52.90xA
Unspecified fracture of
unspecified forearm
•
•
Traumatic amputation
of forearm (S58.-)
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 S52
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
Fracture of wrist and
hand level (S62.-)
Documentation Tips
• 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
Low back pain
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
724.2
M54.5
Low back pain
•
N/A
•
•
•
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-)
Low Back Pain Documentation Tips
• 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.
Trochanteric bursitis
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
726.5
M70.60
Trochanteric bursitis,
unspecified hip
•
•
bursitis NOS
(M71.9-)
•
Applicable to:
Trochanteric tendinitis
M70.70
Other bursitis of hip,
unspecified hip
M76.10
Psoas tendinitis,
unspecified hip
M76.20
Iliac crest spur, unspecified
hip
•
There 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
bursitis of shoulder
(M75.5)
enthesopathies (M76M77)
pressure ulcer (pressure
area) (L89.-)
Documentation Tips
Identify:
• laterality
Carpal tunnel syndrome, unspecified upper limb
ICD-9 Code
ICD-10
Code
Description
Excludes1
Excludes2
354.0
G56.00
Carpal tunnel
syndrome,
unspecified upper
limb
•
N/A
current traumatic nerve
disorder - see nerve injury
by body region
There are more specific code choice selections below:
G56.01
Carpal tunnel syndrome, right upper limb
G56.02
Carpal tunnel syndrome, leftt upper limb
Documentation Tips
Identify:
• Laterality
Unspecified intracapsular fracture of femur
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
820.00
S72.019A
Unspecified intracapsular
fracture of femur
•
•
traumatic amputation
of hip and thigh (S78.-)
Applicable to:
•
Subcapital fracture of femur
•
•
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 S72
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
fracture of lower leg and
ankle (S82.-)
fracture of foot (S92.-)
periprosthetic fracture of
prosthetic implant of hip
(T84.040, T84.041)
Documentation Tips
• 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
Pain in limb
ICD-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)
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
Pain in joint (M25.5-)
Documentation Tips
• Site
• Laterality
• Use an external cause code following the code for
the musculoskeletal condition, if applicable, to
identify the cause of the musculoskeletal condition
Sprain of unspecified rotator cuff capsule
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
840.4
S43.429A
Sprain of unspecified
rotator cuff capsule, initial
encounter
•
•
840.4
S43.429D
Sprain of unspecified
rotator cuff capsule,
subsequent encounter
840.4
S43.429S
Sprain of unspecified
rotator cuff capsule,
sequela
rotator cuff
syndrome
(complete)
(incomplete), not
specified as
traumatic (M75.1-)
•
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
strain of muscle,
fascia and tendon of
shoulder and upper
arm (S46.-)
injury of tendon of
rotator cuff (S46.0-)
Documentation Tips
• 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
Secondary osteoarthritis, shoulder
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
715.21
M19.219
Secondary osteoarthritis,
unspecified shoulder
•
•
Polyarthritis
(M15.1-)
•
•
There are more specific code choice selections below:
M19.211
Secondary osteoarthritis, right shoulder
M19.212
Secondary osteoarthritis, left shoulder
arthrosis of spine
(M47.-)
Hallux rigidus
(M20.2)
osteoarthritis of
spine (M47.-)
Documentation Tips
Identify:
– Laterality
– Primary, Secondary, Post-traumatic
Displaced intertrochanteric fracture of femur
ICD-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.-)
•
•
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 S72
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
fracture of lower leg and
ankle (S82.-)
fracture of foot (S92.-)
periprosthetic fracture of
prosthetic implant of hip
(T84.040, T84.041)
Documentation Tips
• 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
Other specified postprocedural states
ICD-9 Code
ICD-10 Code
Description
Excludes1
Excludes2
V45.89
Z98.89
Other specified
postprocedural states
N/A
N/A
Applicable To:
• Personal history of
surgery, not elsewhere
classified
Code also any follow-up examination (Z08-Z09)
Documentation Tips
Note: Z codes represent reasons for encounters. A corresponding procedure
code must accompany a Z code if a procedure is performed. Categories Z00Z99 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.
Monitor Claims
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
Claim Denial and Management
• 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
Client Responsibilities
• Client will need to update
–
–
–
–
Templates
Order Sets
Superbills
Favorites
• Future Orders
– Remove ICD-9 code add ICD-10 code
Documentation – Start Now
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
–
–
–
–
–
•
•
Indicate acute or chronic
Indicate underlying or external cause factors
–
–
–
–
•
Exacerbation
Manifestations
Relapse
Status
Stages
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
Questions
codingresource@g1hs.com
Centers for Disease Control and Prevention (ICD-10-CM)
http://www.cdc.gov/nchs/icd/icd10cm.htm