rehabbing your documentation for...

Rehabbing Your

Documentation for ICD-10:

Musculoskeletal, Sports, Pain and

Spine Medicine

Sponsored by:

American Academy of Physical Medicine

and Rehabilitation

Annual Assembly 2015

Presented by:

Deborah Grider, CDIP, CCS-P, CPC,

CPC-I, COC, CPC-P, CPMA, CEMC

Here’s How to Reach Us…

Text and Format ©2015 KZA, Inc. 2015 AAPMR_Rehabbing for ICD-10 Session 1 (DG) 090415

1 All Rights Reserved

Be sure to visit our website for useful practice management ideas and course information!

www.karenzupko.com

KZA Disclaimer

This manual is not intended to provide legal advice to physicians and their staffs. If you have specific questions regarding

the permissibility of your billing or other practices, we recommend that you consult legal counsel directly for assistance in

evaluating any legal, regulatory or compliance issues regarding these matters. In the event that you choose to consult with

outside legal counsel, KZA is available to work with such counsel, as appropriate, to meet your needs.

CPT five digit codes, nomenclature and other data are copyright 2014 American Medical Association. All Rights

Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes

no liability for the data contained herein.

KZA Endorses Ethical Coding



As the membership organization of health information management professionals, the American Health Information Management Association (AHIMA) fosters the professional development of its members through education, certification, and lifelong learning thereby promoting quality information to benefit the public, the healthcare consumer, providers, and other users of clinical data. American Health Information Management Association (AHIMA) Standards

Standards of Ethical Coding

Coding professionals should:

1. Apply accurate, complete, and consistent coding practices for the production of high-quality healthcare data.

2. Report all healthcare data elements (e.g. diagnosis and procedure codes, present on admission indicator, discharge status) required for external reporting purposes (e.g., reimbursement and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements and applicable official coding conventions, rules, and guidelines.

3. Assign and report only the codes and data that are clearly and consistently supported by health record documentation in accordance with applicable code set and abstraction conventions, rules, and guidelines.

4. Query provider (physician or other qualified healthcare practitioner) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g., present on admission indicator).

5. Refuse to change reported codes or the narratives of codes so that meanings are misrepresented.

6. Refuse to participate in or support coding or documentation practices intended to inappropriately increase payment, qualify for insurance policy coverage, or skew data by means that do not comply with federal and state statutes, regulations, and official rules and guidelines.

7. Facilitate interdisciplinary collaboration in situations supporting proper coding practices.

8. Advance coding knowledge and practice through continuing education.

9. Refuse to participate in or conceal unethical coding or abstraction practices or procedures.

10. Protect the confidentiality of the health record at all times and refuse to access protected health information not required for coding-related activities (examples of coding-related activities include completion of code assignment, other health record data abstraction, coding audits, and educational purposes).

11. Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities.

Revised and approved by the House of Delegates 09/08

Resources, Updated April 2013

AHIMA Code of Ethics

ICD-9-CM Official Guidelines for Coding and Reporting

AHIMA's position statement on Quality Health Data and Information

AHIMA's position statement on Uniformity and Consistency of Healthcare Data

AHIMA Practice Brief titled "Managing an Effective Query Process Source: AHIMA, All Rights Reserved

library.ahima.org/xpedio/groups/public/documents/ahima/bok2_001166hcsp2dDocName=bok2_001166 12/13/13

Deborah Grider, CDIP, CCS-P, CPC,

CPC-I, COC, CPC-P, CPMA, CEMC

Consultant, Author, and Speaker



Deborah Grider works with physician practices and hospital inpatient and outpatient facilities in solo groups, multi-specialty, academic settings and hospital owned practices providing education to physicians and staff on coding and reimbursement issues, and to evaluate reimbursement processes in the medical practice. Deborah has over 32 years of healthcare industry experience in the clinical setting, and as a practice administrator, medical record auditor, clinical documentation improvement practitioner as well as educator. Deborah Grider is a Certified Professional Coder (CPC), a Certified Professional Coder -Instructor (CPC-I), a Certified Professional Coder-Hospital (COC) a Certified Professional Coder-Payer (CPC-P), a Certified Professional Medical Auditor (CPMA), a Certified Evaluation and Management Specialist (CEMC), with the American Academy of Professional Coders, a Certified Coding Specialist-Physician (CCS-P), and Certified Clinical Documentation Improvement Practitioner (CDIP) with the American Health Information Management Association. Deborah teaches and consults with private practices, physician networks, and hospital-based educational programs nationally. She conducts many seminars throughout the year on coding and reimbursement issues She is the former program director of the Medical Coding Program for IU Health. Deborah is considered a national ICD-10 Implementation expert and has provided testimony for the National Committee on Health Care Vital Statistics on ICD-10 implementation challenges for medical practices. She developed the education and training curriculum for ICD-10 Implementation for Physicians and Payors for the American Academy of Professional Coders, and the ICD-10 Implementation Training for the Indiana and Kentucky Hospital Associations. She has also developed webinars on ICD-10 Implementation for Hospital Systems which broadcasts nationally, writes a monthly article “Fast Tracking ICD-10” for ICD-10 monitor and appears regularly as a panelist on “Talk Ten Tuesday”. She served in 2009-2012 on the ICD-10 Stakeholders Committee in Washington, DC as an advisor on the challenges with ICD-10 Implementation. Deborah provides litigation support to attorneys nationally on behalf of their physician and health system clients. Deborah is the author of Principles of ICD-9-CM, Principles of ICD-10-CM, The ICD-10 Workbook, ICD-10 Implementation Guide, Make the Transition Manageable, Coding with Modifiers, and the Medical Record Auditor for the American Medical Association and has been writing for the AMA since 1998. Deborah is past President of the American Academy of Professional Coders National Advisory Board and was a board member for seven years. She is the current president of the Indiana Health Information Management Association. Ms. Grider was awarded her Bachelor’s degree in Business Administration from Indiana University.

Introduction



There are many daily chores to being a good physician and or practitioner. Patient care,

nursing staff issues, medical decision making, patient paper work and referrals,

constant prescription refill requests; the list goes on and on.

Patient charting is one of those crucial daily tasks, which cannot be overlooked, and

which you must complete to the best of your ability, all the while seeing other patients,

and dealing with all of your other responsibilities in the office. Come October 1, 2015,

this specific responsibility will become even more problematic.

On October 1, 2015 the International Classification of Diseases system (ICD, currently

in its 9th revision) will be updated to the most current system, ICD-10. While this is

mainly a problem for medical billers and coders, it will also affect the way you perform

as a clinician. The ICD-9 system is the set of codes that the entire medical industry uses

to indicate patient diagnosis, condition, or other reason for a visit to the doctor or

healthcare facility. Although some of the codes are updated every year, the entire ICD-9

system has not been completely re-designed for at least a decade.

This has led to the development of the newest revision of ICD codes, the 10th edition,

which is already in use throughout Europe. This new edition contains thousands of new

codes and allows for some of the most precise diagnoses to be indicated with a specific

set of numbers and letters. Again, assigning these codes and sending them to

insurance will be the job of medical billers and coders, but as a physician, you will be

required to change the way you document the majority of your patient encounters.

ICD-10 is implementing new documentation requirements in order to support the

specificity needed for the new codes. The type of additional documentation needed will

depend on the types of patient visits and the diagnoses reported.

If the patient visit is more complex, your documentation will also have to be much more

complex, containing details that will be necessary in order to assign the correct

diagnosis code per ICD-10. For example, your patient is a middle-aged woman who

was cooking in her kitchen, when a cabinet fell off the wall and hit her in the head,

causing a concussion and intractable headaches. Because of the many variables in this

scenario, your documentation must be as specific as possible, keeping in mind the

many different aspects that you will need in order for the medical coders to assign the

correct ICD-10 codes.

Introduction



These variables include:

Type of encounter (initial or subsequent)

Applied specificity (Did the patient lose consciousness?)

Acute versus chronic

Relief or non-relief (intractable versus non-intractable)

External cause (What caused the accident?)

Activity (What was the patient doing when she was injured?)

Location (Where was the patient when she was injured?)

Believe it or not, all of these factors must be documented in order to accurately code the

entire claim. These are not all of the necessary factors, however, and different patient

visits will require different types of documentation. What this means is that if your

documentation does not include all of the different necessary aspects, your claims will

not be going out correctly, which will end up affecting the bottom line for your practice.

All practitioners whether physicians or non-physician practitioners will have to know all

of the documentation requirements for the diagnoses you report. Knowing the increased

documentation requirements will not only help your claims get paid, it will also help you

become the best practitioner you can be.

Clinical Documentation Improvement



What is Clinical Documentation Improvement?

Clinical documentation improvement, commonly referred to as CDI, is a process in which to ensure that the practitioners are documenting clearly and concisely and that the documentation supports quality initiatives. When asking physicians why good clinical documentation is necessary, they will most likely say that it is to document the care of the patient and to communicate with other providers. Physicians understand the need to make documentation legible, timely, complete, precise, and clear. They understand that the documentation is the legal health record. They understand the common phrase “If you didn’t document it, it did not happen.” Good Clinical Documentation Will:

Improve Communication

Validate care provided Increase recognition of

comorbid conditions

Maintain compliance with quality and safety

initiatives

Support all services provided




Physicians and non-physician practitioners may incorrectly assume that a busy practice equals revenue in the door. What CDI practitioners typically hear is, “we got paid so the coding and documentation must be correct.” That assumption is not always accurate. The insurance carriers use computer systems that initially adjudicate the claims and pay them and typically data mine to audit and monitor claims for inappropriate payment. Insurance carriers can ask for reimbursement refunds from providers who do not code or document accurately for the service provided. For government payers, additional fines and penalties can apply. Every patient encounter begins with documentation. Documentation should accurately depict the patient’s complexity along with the services provided, including, but not limited to:

Office visits

Hospital visits

Diagnostic tests and procedures

Radiology services

Ancillary services

Surgical procedures

Other services

CDI Tip

Documentation begins and ends with the physician in

every healthcare setting.

Cd




The patient medical record tells the story of the patient encounter from beginning to end. Clinical documentation improvement (CDI) goes beyond good compliance practices of auditing and monitoring by working toward improving documentation and coding on an ongoing basis.

Most CDI programs are focused on hospital documentation and coding, but in reality, documentation begins and ends with the practitioners (physicians and non-physicians) and should be a medical practice initiative. Clinical Documentation Improvement (CDI) can:

Bridge the gap between the clinicians and coding and billing systems.

Increase and capture appropriate reimbursement for services provided. CDI also refers to the process of improving documentation to better reflect the severity of the patient encounter, as well as to:

Justify the medical necessity for services rendered.

Assist with assigning E/M or procedure codes to support medical necessity.

Help receive accurate reimbursement. While the electronic health record (EHR) has improved the legibility and timeliness of documentation, documentation has become more “cloned” than ever. In an EHR, all of the documentation has started to look the same for every encounter, which can invalidate the encounter during a carrier audit. For many years we have been teaching physicians how to document their evaluation and management (E/M) services, surgical and diagnostic procedures, etc. to get paid for the complexity of their patients, but we have not focused on adding specificity to their diagnoses to support quality of care and medical necessity.

Severity of Illness

Complexity of Care

Resources Utilized in the

Medical Practice




One of the pitfalls of the EHR is that it allows the practitioner to pull information from the patient’s previous visit into the current encounter, which can cause outdated information or misinformation to be entered into the record. If physicians are not familiar with specificity of the diagnosis, make it easy for the physician to provide the correct diagnosis by building logic trees to drill down to specificity. When the practitioner uses a pick-list or a favorites list to select the diagnosis, sometimes the first item on the list is the item chosen, or the list build is not specific and uses more unspecified diagnosis codes, which could be a costly mistake. If using a pick-list it must be compliant and must not lead the physician to choose only a non-specific diagnosis. The medical record must be organized and legible, and every entry must be signed and dated which can be accomplished electronically in the EHR.

Good documentation is the key to supporting services billed on any insurance claim.

Many practitioners are under the assumption that the diagnosis is not that important because they are paid based on the Current Procedural Terminology (CPT

®) and

Healthcare Common Procedure Coding System (HCPCS) codes and the relative value unit (RVU) of the service. But that is not the case. Any claims submitted must:

Include a valid CPT/HCPCS code.

Include the appropriate documentation that supports the code.

Support medical necessity (the overarching criterion for selecting a procedure or service).

It is important to understand that the diagnosis code is just as important. This will be even more important with the implementation of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code set, with its expanded specificity and more detail built into the diagnosis code(s).




Keep in mind that health care reimbursement continues to operate under the numerous regulations and compliance requirements that depend on good documentation. Documentation:

Plays a key role in performance and core measures.

Supports accurate clinical documentation.

Provides a good defense for documentation and coding reviews.

Helps reduce risk and vulnerability from: o Insurance carrier audits o Government payers o Recovery audit contractors (RACs) o Medicaid integrity contractors (MICs) o Zone program integrity contractors (ZPICs) o Office of Inspector General (OIG)

Typically a documentation review (i.e., “audit”) is performed after a claim has been submitted, which leaves the practitioner vulnerable to scrutiny if the documentation does not support the procedure and diagnoses reported on the claim. Clinical documentation improvement (CDI) is a process of reviewing documentation prior to claim submission to avoid inaccurate claim submission. A query is the process in which the physician or non-physician practitioner may clarify coding and/or documentation previously submitted. A query is a question posed to the provider to obtain additional information, clarify documentation, or request an amendment to the medical record in order for the claim to be submitted properly. A query can be a communication and education method to advocate proper documentation practices. The CDI process can help ensure that all procedures and diagnoses are validated in the documentation. If a question arises, the practitioner is sent a query, which can be written or electronic. Many CDI programs utilize the physician query as the method of communication. Queries can be verbal, on paper, or electronic, but the challenge is how to monitor, track, and trend the response to the query. Paper Queries:

• Try to include the query within the progress note or order to ensure that it will be seen by the physician.




Electronic Documentation:

• Lends itself better to tracking the data, but getting the documentation into the electronic health record can be more of a challenge.

• An electronic query form that could be easily accessible to the physician, preferably while they are reviewing the clinical record.

• The physician should be able to answer the form electronically and route it back to the CDI specialist/practitioner.

• The completed electronic form should be reviewed to ensure that the documentation is complete.

The presenting problem(s) assists with supporting medical necessity for the patient encounter and assists with accurate reimbursement. It is important to capture all clinical conditions that are managed, treated, worked-up, or monitored with appropriate specificity in the documentation that supports all of the services performed and most important, justifies medical necessary.




How physicians use the electronic health record (EHR) can have a big impact on CDI. EHR technology has clearly improved the legibility and timeliness of clinician documentation. Physicians can use structured templates to input documentation, or they can dictate into a standard progress note format. The problem with the structured templates is that they are not always customized to meet the specific needs of the type of patients treated in the practice. The templates that are normally standard in the EHR should be customized for compliance. Along with all of the benefits of electronic documentation, there are also some significant challenges with electronic documentation. These include:

Cutting and pasting prior documentation into new records, which can obscure new information and increase audit risks.

Many times it is unclear who provided the service.

Symptoms, not diagnoses, are often documented.

Doctors can’t find correct diagnosis from pick-list so they select the first one they see.

Some diagnoses are captured in the problem list and not in the assessment and plan of care.

Some physicians only look in the EHR for information/communication, which can cause a lack of communication in their workflow.

Documentation is not always signed appropriately. Many physicians have embraced electronic documentation since it allows them to quickly complete the daily note. Some physicians like to keep a daily log of events in their notes, so if another practitioner has to cross-cover the patient they only need to read the last note in the chart. This presents a challenge to any coder, clinical documentation improvement practitioner, or auditor who has to review the chart.

Reading the same cut-and-pasted documentation can significantly

decrease productivity and increase the chance for missed opportunities

for coding or documentation clarification. It also promotes “cloning”

which is not an accepted practice.



Format and

Structure of

ICD-10

ICD-10: Is Anything the Same?



The layout of the code set is one area where ICD-10-CM is comparable to ICD-9-CM. It is divided into two main sections: the Alphabetic Index and the Tabular List.

The Alphabetic Index is arranged in alphabetic order by disease, specific illness, injury, eponym, abbreviation or other descriptive diagnostic term. The Index also lists diagnostic terms for other reasons for encounters with health care professionals. The Neoplasm Table provides the proper code based upon histology of the neoplasm and site.

The Neoplasm Table is now located immediately after the main alphabetic index rather than placed alphabetically within it.

The Table of Drugs and Chemicals lists the drug and specific codes that identify the drug and the intent. The Index to External Causes of Injuries is arranged in alphabetic order by main term indicating the event.

Hypertension table has been removed from the Alphabetic Index.

The Tabular List contains codes and descriptors arranged alphanumerically according to body system or condition.

Contains: -Index to Diseases and Injuries

Also includes:

-Neoplasm Table

-Table of Drugs and Chemicals

-Index to External Cause of Injuries

Alphabetic Index List of

alphanumeric codes divided into chapters based on condition and/or body system

Contains categories, subcategories and valid codes

Tabular List

What’s the Difference?



Never select a code directly from the Alphabetic Index. Always confirm final code selection by verifying it in the Tabular List.

Steps to Correct Code Selection

1. Look up the main term in the Alphabetic Index and scan subterm entries making

sure to review additional subterms that may continue into the next column or page. 2. Note all parenthetical terms (nonessential modifiers) that help in code selection, but

do not affect code assignment. 3. Pay attention to instructions in the Index:

“See,” “see also,” and “see category” cross-references

“With”/“without” notes

“Due to” subterms

Other instructions found in note boxes, such as “code by site” 4. Never code from the Alphabetic Index without verifying the accuracy of the code in

the Tabular List. Locate the code in the alphanumerically arranged Tabular List. 5. Read all instructional material:

“Includes” and both types of “excludes” notes

“Use additional code” and “code first underlying disease” instruction

“Code also”

Fourth-, fifth- and sixth-character requirements and seventh-character extension requirement

Age and sex symbols 6. Use the official Draft ICD-10-CM guidelines that govern use of specific codes. 7. Confirm and assign the correct code.

The ICD-10-CM code set is comprehensive and brings with it significant changes not only to the codes themselves, but the overall organization and structure as well.

What’s the Difference?



Certain chapters have been reorganized.

Supplemental classifications (ICD-9-CM V and E codes) are now incorporated in the

main classification in ICD-10-CM.

The number of chapters was increased to 21 from 19.

o Chapter 7 Diseases of the Eye and Adnexa (H00 – H59)

o Chapter 8 Diseases of the Ear and Mastoid Process (H60 – H95)

o External Causes of Morbidity (previously E-codes) and Factors Influencing

Health Status and Contact with Health Services (previously V-codes) have

been incorporated into the main classification.

Injury codes are now grouped by specific site (e.g., nose, ear, eyelid),

then by type of injury (e.g., fracture, open wound).

o S39 Other and unspecified injuries of abdomen, lower, back, pelvis and

external genitals

S39.9 Unspecified injury of abdomen, lower, back, pelvis and

external genitals

• S39.93 Unspecified injury of pelvis

o S39.93XA Unspecified injury of pelvis initial

encounter

Some postoperative complications have been moved to specific body system

chapters.

See Page i of the

ICD-10-CM coding

book for a

complete list of

chapters.

What Makes Up the Code?



The ICD-10-CM code set has a broad range of categories for diseases and other health-related conditions. The detail within the codes has been greatly increased by the addition of separate codes for laterality and additional characters that provide even more information about the injury, illness and/or disease.

ICD-9-CM Code Structure

ICD-10-CM Code Structure

• Utilizing all letters except "U." Codes are alphanumeric

• Not all codes contain seven characters; valid codes can be 3, 4, 5, 6, or 7 characters.

Codes are up to seven characters in length

• Do not need to reference back to common fourth and fifth digits like in ICD-9-CM.

Includes full code titles for all codes




The chapters in ICD-10-CM are made up of categories, subcategories and codes

consisting of alphanumeric characters that can be up to seven characters in length.

Categories are 3 characters

Three-character categories that are not further subdivided are equivalent to a

code.

o M25 Other joint disorders, not elsewhere classified

Subcategories are 4 or 5 characters

Each subdivision after a category is a subcategory.

o M25.5 Pain in joint

o M25.56 Pain in knee

Codes may be 4, 5, 6, or 7 characters

The final level of subdivision is a valid code.

o M25.561 Pain in right knee

o M35.562 Pain in left knee

o M25.569 Pain in unspecified knee

Codes that have applicable 7th characters are still codes, but need the 7th

character extension appended to be a valid code for submission.

o S63.522A Sprain of radiocarpal joint of left wrist




Category

S79

Unspecified injury of hip

Subcategory

S79.912

Unspecified injury of left

hip

Code S79.912D

Unspecified injury of left

hip, subsequent encounter

7th

Character Extension and the

“X” Placeholder



Some codes require a 7th character to be added for a complete, valid code.

Remember not all codes are seven characters.

There are valid three, four, five and six character codes.

Pertinent codes for Physical Medicine and Rehab that require a seventh character

mainly fall into injury categories including: fractures, foreign bodies and open

wounds.

The Tabular List will note how many characters are required for a code to be valid.

√ 7th S46.01Strain of muscle(s) of the rotator cuff of shoulder

When seeing this √ 7th character notation, the applicable seventh character options will

be at the code category level and must be appended to report a valid code.

Seventh character extensions are not the same for all code categories as noted by the

two examples below.

T46.012A Strain of muscle(s) and tendon(s) of the rotator cuff of the

left shoulder, initial encounter

S46 Strain of muscle(s) and tendon(s) of the rotator cuff of shoulder

The appropriate 7th character is to be added to each code from category S46

A = initial encounter

D = subsequent encounter

S = sequela

7th


“X” Placeholder



S42 Fracture of shoulder and upper arm

The appropriate 7th character is to be added to each code from category S42.

A = initial encounter for closed fracture

B = initial encounter for open fracture

D = subsequent encounter for fracture with routine healing

G = subsequent encounter for fracture with delayed healing

K = subsequent encounter for fracture with nonunion

S = sequela

A 7th character is required for all codes within the category, or as the notes in

the Tabular List instruct. The 7th character must always be the 7th character in

the data field. If a code that requires a 7th character is not 6 characters, a

placeholder X must be used to fill in the empty characters.

7th


“X” Placeholder



2016 ICD-10-CM Guidelines for 7th Character Extensions

While the patient may be seen by a new or different provider over the course of

treatment for an injury, assignment of the 7th character is based on whether the

patient is undergoing active treatment and not whether the provider is seeing

the patient for the first time.

The 7th character “A”, initial encounter is used while the patient is receiving active

treatment for the condition. Examples of active treatment are: surgical treatment,

emergency department encounter, and evaluation and continuing treatment by

the same or a different physician.

7th character “D” subsequent encounter is used for encounters after the patient

has received active treatment of the condition and is receiving routine care for the

condition during the healing or recovery phase. Examples of subsequent care are:

cast change or removal, an x-ray to check healing status of fracture, removal

of external or internal fixation device, medication adjustment, other aftercare and

follow up visits following treatment of the injury.

7th character “S” sequela is used when there is a residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Examples of sequela include: scar formation resulting from a burn, deviated septum due to a nasal fracture, and infertility due to tubal occlusion from old tuberculosis. Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is sequenced second. An exception to the above guidelines are those instances where the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect or condition.

7th


“X” Placeholder



S41 Open wound of shoulder and upper arm

The appropriate 7th character is to be added to each code from category S41

A = initial encounter D = subsequent encounter S = sequela

√x7th S41.02 Laceration with foreign body of shoulder

Incorrect code assignment: T41.02A Correct code assignment: T41.021A

Note the box indicating to check the 7th character, an “x” is after the check mark to point out the code will require an “x” be placed in the empty character positions

to be able to assign the 7th character extension.

The “X” placeholder also serves another purpose in ICD-10-CM. It is used with certain codes to allow for future code expansion. The “X” placeholder must be used in order for the code to be considered valid.

Adverse effect after taking Oxycodone for pain

Incorrect code assignment: T40.2A

Correct code assignment: T40.2X5A

7th


“X” Placeholder



At first glance it may seem apparent what the meaning of individual seventh character

extensions are; however those terms can be deceiving. The healing process guides the

extension selection, not chronology of the visits.

Initial Encounter = A

This extension is used when the patient is receiving active treatment for the condition.

Examples include: Surgical treatment, emergency department encounter and

evaluation and treatment by a new physician

Subsequent Encounter = D

This extension is used for encounters after the patient has received active treatment

and is now in the healing phase receiving routine care for the condition.

Examples include: Cast change or removal, removal of external or internal fixation

device, medication adjustment, other aftercare and follow up

visits following treatment of the injury or condition

Subsequent encounter does not equal established patient.

Sequela = S

ICD-10-CM no longer has late effect codes. To indicate a condition is the result of a

previous injury, the 7th character extension “S” is used on the active injury code. A code

for the current condition is also used. An example is a scar resulting from a previous

laceration. The scar is the “late effect” or “sequela” of the laceration.

When using this extension it is necessary to use both the injury code that is the cause of

the sequela and the code for the sequela itself.



ICD-10 Documentation

for Musculoskeletal, Sports, Pain and Spine Medicine




The Electronic Health Record Many Electronic Health Records use IMO (Intelligent Medical Objects) along with the EHR. With this technology the system is able to build qualifiers or logic to allow for code selection easier than a “pick-list.”




Pain Codes

You can find pain codes in three different places in the ICD-10 CM manual:

Pain that points to a disorder of a specific body system is classified in the body

system chapters. For example, low back pain is classified in the Musculoskeletal

chapter (M54.5).

Pain that does not point to a specific body system is classified in the Symptoms

and Signs chapter. For example, abdominal pain is classified to category R10.

Certain specific types of pain are classified to category G89 (Pain, not elsewhere

classified) in the Nervous System chapter.




Case 1 - Cervical Spondylosis w/o Myelopathy, Myofascial Pain, Cervical

Dystonia, Multi-level Degenerative Disc Disease, and Cluster Headaches

Cervical Spondylosis w/o Myelopathy

ICD-9 ICD-10

721.0

Cervical spondylosis without myelopathy

M47.811 M47.812 M47.813 M47.814 M47.815 M47.816 M47.817 M47.818 M47.819

Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region Spondylosis without myelopathy or radiculopathy, cervicothoracic region Spondylosis without myelopathy or radiculopathy, thoracic region Spondylosis without myelopathy or radiculopathy, thoracolumbar Spondylosis without myelopathy or radiculopathy, lumbar region Spondylosis without myelopathy or radiculopathy, lumbosacral Spondylosis without myelopathy or radiculopathy, sacral an sacrococcygeal Spondylosis without myelopathy or radiculopathy, site unspecified




Myofascial Pain

ICD-9 ICD-10

729.1

Unspecified myalgia and myositis

M60.80 M60.88 M60.89 M60.811 M60.812 M60.819 M60.821 M60.822 M60.829 M60.831 M60.832 M60.839 M60.841 M60.842 M60.849 M60.851 M60.852 M60.859 M60.861 M60.862 M60.869 M60.871 M60.872 M60.879 M60.9

Other myositis, unspecified site Other myositis, other site Other myositis, multiple sites Other myositis, right shoulder Other myositis, left shoulder Other myositis, unspecified shoulder Other myositis, right upper arm Other myositis, left upper arm Other myositis, unspecified upper arm Other myositis, right forearm Other myositis, left forearm Other myositis, unspecified forearm Other myositis, right hand Other myositis, left hand Other myositis, unspecified hand Other myositis, right thigh Other myositis, left thigh Other myositis, unspecified thigh Other myositis, right lower leg Other myositis, left lower leg Other myositis, unspecified lower leg Other myositis, right ankle and foot Other myositis, left ankle and foot Other myositis, unspecified ankle and foot Myositis, unspecified

Cervical Dystonia

ICD-9 ICD-10

333.83 Spasmodic torticollis G24.3 Spasmodic torticollis




Multi-level Degenerative Disc Disease

ICD-9 ICD-10

722.6

Degeneration of intervertebral disc, site unspecified

M51.34 M51.35 M51.36 M51.37

Other intervertebral disc degeneration, thoracic region Other intervertebral disc degeneration, thoracolumbar region Other intervertebral disc degeneration, lumbar region Other intervertebral disc degeneration, lumbosacral region




Headache

ICD-9 ICD-10 784.0 Headache R51

G44.001 G44.009 G44.011 G44.019 G44.021 G44.029 G44.031 G44.039 G44.041 G44.049 G44.051 G44.059 G44.091 G44.099 G44.1 G44.201 G44.209 G44.211 G44.219 G44.221 G44.229 G44.301 G44.309

Headache Cluster headache syndrome, unspecified (intractable) Cluster headache syndrome, unspecified (not intractable) Episodic cluster headache, intractable Episodic cluster headache, not intractable Chronic cluster headache, intractable Chronic cluster headache, not intractable Episodic paroxysmal hemicrania, intractable Episodic paroxysmal hemicrania, not intractable Chronic paroxysmal hemicrania (intractable) Chronic paroxysmal hemicrania, (not intractable) Short lasting unilateral neuralgiform headache w/conjunctival injection and tearing (SUNCT), intractable Short lasting unilateral neuralgiforml headache with conjunctival injection and tearing (SUNCT), not intractable Other trigeminal autonomic cephalgias (TAC), intractable Other trigeminal autonomic cephalgias (TAC), not intractable Vascular headache, not elsewhere classified Tension-type headache, unspecified, intractable Tension-type headache, unspecified, not intractable Episodic tension-type headache, intractable Episodic tension-type headache, not intractable Chronic tension-type headache, intractable Chronic tension-type headache, not intractable Post-traumatic headache, unspecified, (intractable) Post-traumatic headache, unspecified, (not intractable)




Headache (Continued)

ICD-9 ICD-10 784.0 Headache G44.311

G44.319 G44.321 G44.329 G44.40 G44.41 G44.51 G44.52 G44.53 G44.59 G44.81 G44.82 G44.83 G44.84 G44.85 G44.89

Acute post-traumatic headache, (intractable) Acute post-traumatic headache, (not intractable) Chronic post-traumatic headache, (intractable) Chronic post-traumatic headache, (not intractable) Drug-induced headache, not elsewhere classified, (not intractable) Drug-induced headache, not elsewhere classified, (intractable) Hemicrania continuous New daily persistent headache (NDPH) Primary thunderclap headache Other complicated headache syndrome Hypnic headache Headache associated with sexual activity Primary cough headache Primary exertional headache Primary stabbing headache Other headache syndrome




Clinical Example

POSTPROCEDURE DIAGNOSES: 1. Cervical spondylosis without myelopathy 2. Myofascial pain syndrome 3. Cervical dystonia 4. Status post C5-6 anterior cervical fusion 5. Multilevel degenerative disc disease 6. Headaches 7. Hypertension 8. Hypothyroidism

PROCEDURE: Trigger Point Injections

The risks, benefits, complications, and alternatives to the procedure were discussed in detail and informed written consent was obtained. INDICATIONS: The patient is here to follow up on cervical spondylosis w/o myelopathy (cervicothoracic region), myofascial pain (right shoulder), cervical dystonia, (lumbar region) DDD, and cluster headaches. She is a long-term patient of mine at the Pain Management Clinic and has requested transference because of insurance reasons. Today, she is here for continued management of her many neck-related complaints. Among these are spasms and ongoing pain for which she receives long-acting opioids. She states that she is in fact doing quite well since her cervical fusion. She is requesting that we decrease her medications from 480 mg to 240 mg to 360 mg of morphine per day in the form of Avinza. She also is quite pleased with her other medication regimen which has been greatly simplified over the past year. Some other treatment modalities that have been helpful have included cervical epidural steroid injections. The patient is requesting to have another injection. She states the relief lasted anywhere from four to six months. I agree, this may be helpful because of her intermittent radicular symptoms, particularly in light of her recent surgery. She does complain of hand tingling and numbness, although she is not dropping objects or having difficulties with coordination. In addition, the steroid injections may help expedite her desire to decrease her reliance on medications which have been over-sedating as well as racked with other side effects. DETAILS OF PROCEDURE: Alcohol prep and sterile technique were used. A total of 6 cc of preservative-free 1% lidocaine was used and injected into eight different sites using a 25-gauge, 1-1/2-inch needle at the trapezius muscles bilaterally as well as the levator scapulae, the splenius capitis, and the semispinalis musculature. The procedure was well tolerated.

TREATMENT PLAN:

1. The patient is tentatively scheduled for a cervical epidural steroid injection on March 14, 2005.

2. We will begin a weaning schedule for the patient's Avinza by decreasing in 60 mg intervals. The patient will have a target of 120 mg p.o. b.i.d. and then be reassessed. This is expected to occur after her cervical epidural steroid injection.




Coding

ICD-9 ICD-10

721.0 729.1 333.83 722.6 784.0

Cervical spondylosis w/o myelopathy Unspecified myalgia and myositis Cervical dystonia Degeneration of intervertebral disc, site unspecified Headache

M47.813 M60.811 G24.3 M51.36 G44.009

Spondylosis without myelopathy or radiculopathy, cervicothoracic region Other myositis, right shoulder Spasmodic torticollis Other intervertebral disc degeneration, lumbar region Cluster headache syndrome, unspecified (not intractable)

Documentation for Cervical Spondylosis w/o Myelopathy will need to specify:

Region

Occipito-atlanto-axial

Cervical

Cervicothoracic

Thoracic

Thoracolumbar

Lumbar

Lumbosacral

Sacral and sacrococcygeal




Documentation for Myofascial Pain will need to specify:

Type

o Laterality (right/left) o Multiples sites o Shoulder o Arm o Forearm o Hand o Thigh o Lower leg o Ankle and foot o Other

Documentation for Cervical Dystonia will need to specify:

Type of dystonia

Documentation for Multi-level Degenerative Disc Disease will need to specify:

Region

o Thoracic o Thoracolumbar o Lumbar o Lumbosacral

Documentation for Headaches will need to specify:

Type o Intractable o Not intractable o Chronic o Episodic o Drug induced o Post-traumatic o Exertional o Stabbing o Cluster, etc.




Case 2 - Carpal Tunnel Syndrome

Carpal Tunnel Syndrome

ICD-9 ICD-10

354.0 Carpal tunnel syndrome G56.00 G56.01 G56.02

Carpal tunnel syndrome, unspecified upper limb Carpal tunnel syndrome, right upper limb Carpal tunnel syndrome, left upper limb

Clinical Example

This is an established patient who has been complaining of left wrist pain for approximately one year. She has been receiving physical therapy for six months and it does not seem to be helping. She is a customer service representative and does repetitive computer work. She has been wearing bilateral wrist supports, which have helped to some extent. Patient has left wrist weakness, unable to touch thumb and little finger together. There is a prominent mass on the palmar aspect of the left wrist.

Assessment and Plan: Patient has carpel tunnel syndrome and will be referred to the orthopedic surgeon for a carpal tunnel surgery. In the meantime, I have placed the patient on pain medication.

Coding

ICD-9 ICD-10

354.0 Carpal tunnel syndrome G56.02 Carpal tunnel syndrome, left upper limb

Documentation required for Carpal Tunnel Syndrome will need to specify:

• Laterality o Right o Left




Case 3 - Bursitis (Hand or Wrist)

Bursitis (Hand or Wrist)

ICD-9 ICD-10

726.4 Enthesopathy of wrist and carpus

M25.731 M25.732 M25.739 M25.741 M25.742 M25.749 M70.10 M70.11 M70.12 M77.20 M77.21 M77.22 M77.8

Osteophyte, right wrist Osteophyte, left wrist Osteophyte, unspecified wrist Osteophyte, right hand Osteophyte, left hand Osteophyte, unspecified hand Bursitis, unspecified hand Bursitis, right hand Bursitis, left hand Periarthritis, unspecified wrist Periarthritis, right wrist Periarthritis, left wrist Other enthesopathies, not elsewhere classified

Clinical Example The patient presents for an injection for bursitis of the left hand. After the suitable risks of the injection were discussed with the patient, including infection and elevated blood glucose levels, and there were no known allergies to the materials involved with the injection, the patient chose to proceed. The area was cleansed with Hibistat. Using a clean, sterile, no touch technique, a 22 gauge spinal needle entered over the mid-trochanter with the patient in a lateral decubitus position, the needle was advanced to the hand then withdrawn slightly to inject 10 mL of Xylocaine 1%. Following this, the syringe with the Xylocaine was removed while the needle was left intact and 1 mL of Depo-Medrol 80 was injected. This was done without complications. The patient was told that the injection may cause more pain for two to three days afterwards and if this occurred they would best be served by icing the area 15-20 minutes every 6 hours. The patient was advised to protect the left hand by limiting repetitive usage and lifting for a week. Also, they were asked to follow up in two weeks p.r.n.




Coding

ICD-9 ICD-10

726.4 Enthesopathy of wrist and carpus

M70.12 Bursitis, left hand

Documentation requirements will need to specify:

• Laterality (right or left) • Hand • Wrist • Osteophyte • Bursitis • Periarthritis • Other




Case 4 - Brachial Neuritis or Radiculitis, Lumbago, and Sciatica

Brachial Neuritis or Radiculitis

ICD-9 ICD-10

723.4 Brachial neuritis or radiculitis NOS

M54.10 M54.11 M54.12 M54.13 M54.14 M54.15 M54.16 M54.17 M54.18

Radiculopathy, site unspecified Radiculopathy, occipito-atlanto-axial region Radiculopathy, cervical region Radiculopathy, cervicothoracic region Radiculopathy, thoracic region Radiculopathy, thoracolumbar Radiculopathy, lumbar region Radiculopathy, lumbosacral Radiculopathy, sacral and sacrococcygeal region

Low Back Pain

ICD-9 ICD-10

724.2 Lumbago M54.40 M54.41 M54.42 M54.5

Lumbago w/sciatica, unspecified side Lumbago w/sciatica, right side Lumbago w/sciatica, left side Low back pain

Sciatica

ICD-9 ICD-10

724.3 Sciatica M54.30 M54.31 M54.32 M54.40 M54.41 M54.42

Sciatica, unspecified side Sciatica, right side Sciatica, left side Lumbago w/sciatica, unspecified side Lumbago w/sciatica, right side Lumbago w/sciatica, left side




Clinical Example

PROCEDURE: Cervical epidural steroid injection without fluoroscopy. ANESTHESIA: Local sedation. VITAL SIGNS: See nurse's notes. COMPLICATIONS: None. DIAGNOSES:

1. Brachial neuritis 2. Low back pain 3. Sciatica

DETAILS OF PROCEDURE: The patient was in the sitting position. The posterior neck and upper back were prepped with Betadine. Lidocaine 1.5% was used for skin wheal made between C7-T1. An 18-gauge Tuohy needle was placed into the epidural space using loss of resistance technique and no cerebrospinal fluid or blood was noted. After negative aspiration, a mixture of 5 cc preservative-free normal saline plus 160 mg Depo-Medrol was injected for the brachial neuritis (cervicothoracic region), low back pain (with sciatica, right side). Neosporin and Band-Aid were applied over the site. The patient discharged to recovery room in stable condition.

Coding

ICD-9 ICD-10

723.4 724.2 724.3

Brachial neuritis or radiculitis NOS Low back pain Sciatica

M54.13 M54.5 M54.31

Radiculopathy, cervicothoracic region Low back pain Sciatica, right side

Note: In the clinical example above, the ICD-10 diagnosis for low back pain with sciatica can also be coded as a combination code (e.g. low back pain with sciatica, right side M54.41).




Documentation required for Brachial Neuritis will need to specify:

• Region o Occipito-atlanto-axial o Cervical o Cervicothoracic o Thoracic o Thoracolumbar o Lumbar o Lumbosacral o Sacral and sacrococcygeal

Documentation for Low Back Pain will need to specify:

• Type (if known) • Laterality (right or left) • Sciatica

Documentation for Sciatica will need to specify:

• Laterality (right or left side) • Lumbago w/sciatica




Case 5 - Pain in Joint, Shoulder Region

Pain in Joint, Shoulder Region

ICD-9 ICD-10

719.41 Pain in joint, shoulder region M25.511 M25.512 M25.519

Pain in right shoulder Pain in left shoulder Pain in unspecified shoulder

Clinical Example

CHIEF COMPLAINT: Shoulder pain. HISTORY OF PRESENT PROBLEM: Mrs. Jones has had a six-month history of some shoulder pain (right shoulder), and it has not gotten much better. She does not have a history of trauma. It does bother her at night when she sleeps, and she is here now to have it checked out. She has no other focal findings, no numbness or tingling to the fingers and no soreness at the elbow or neck. She is right hand dominant. CLINICAL/PHYSICAL EXAMINATION: Musculoskeletal: Reveals a positive Hawkins sign to the right shoulder with full range of motion and minor tenderness in the rhomboids and to palpation along the ridge of the scapula. No winging of the scapula. Internal/external rotation is intact. No obvious signs of rotator cuff pathology or slack lesion. Elbow and wrist exams are otherwise unremarkable. Contralateral hand exam for comparison reveals no focal findings. CLINICAL IMPRESSION: Right shoulder impingement. EVALUATION/TREATMENT PLAN: At this point, with her consent, explaining the risks and benefits, we talked about cortisone shots. We will try some therapy, pain medicine only as needed and a sleep aide as needed, and then follow-up. If it is not better, she could consider an MRI before coming to visit and we will re-assess. We will consider a cortisone shot at that point. All questions were answered. Therapy for shoulder impingement was outlined.




Coding

ICD-9 ICD-10

719.41 Pain in joint, shoulder region M25.511 Pain in right shoulder

Documentation for Pain in Joint, Shoulder Region will need to specify:

• Laterality o Right

o Left

o Bilateral




Case 6 - Plantar Fascial Fibromatosis

Plantar Fascial Fibromatosis

ICD-9 ICD-10

728.71 Plantar fascial fibromatosis M72.2 Plantar fascial fibromatosis

Clinical Example

PROCEDURE: Plantar Fascia Injection DIAGNOSES:

1. Plantar fasciitis

Informed consent was obtained from the patient. Special mention was made of the possibility of infection and necrosis of the heel pad. The patient was placed in the supine position. The tender area in the medial aspect of the heel was identified by palpation. After proper preparation with antiseptic solution of the skin, a syringe containing 2 mL of 1% lidocaine was attached to 1.5" 27 gauge needle. The needle was carefully advanced through the carefully identified point at a right angle to the skin, directly towards the central and medial aspect of the calcaneus. The needle was advanced very slowly until the needle impinged on the bone, and then was withdrawn slowly. The contents of the syringe were then gently injected. Subsequently, the needle was left in place and a syringe containing 2 mL of 0.25% Marcaine and 1 mL of Depo-Medrol was attached to the needle and injected after aspiration at this site. Subsequently the needle was removed. Pressure was applied at the site of insertion and once it was made sure there was no bleeding taking place, a small bandage was applied.

Coding

ICD-9 ICD-10

728.71 Plantar fascial fibromatosis M72.2 Plantar fascial fibromatosis

There are no additional documentation requirements for Plantar Fascial Fibromatosis.




Case 7 - Lesion of Plantar Nerve

Lesion of Plantar Nerve

ICD-9 ICD-10

355.6 Lesion of plantar nerve G57.60 G57.61 G57.62

Lesion of plantar nerve, unspecified lower limb Lesion of plantar nerve, right lower limb Lesion of plantar nerve, left lower limb

Clinical Example

PROCEDURE: Morton’s Neuroma Injection DIAGNOSES:

1. Lesion of plantar nerve

Informed consent was obtained from the patient. The patient was placed in the supine position. The Morton's neuroma was localized by careful palpation and was found to be between the plantar nerve (right lower limb). The area was cleaned and subsequently a 25 gauge needle was inserted half way between the MTP heads and advanced in a vertical position down through the transverse metatarsal ligament. 0.5 mL of Depo-Medrol and 0.5 mL of 0.25% Marcaine were injected at this site after aspiration. Post-procedure no complications were noted. Pressure was applied for a period of two minutes and a small dressing applied.

Coding

ICD-9 ICD-10

355.6 Lesion of plantar nerve G57.61 Lesion of plantar nerve, right lower limb

Documentation for Lesion of Plantar Nerve will need to specify:

Laterality (right or left) lower limb




Case 8 - Pain in Joint, Lower Leg, Occipital Neuralgia and Neck Pain

Pain in Joint, Lower Leg

ICD-9 ICD-10

719.46 Pain in joint in lower leg M25.561 M25.562 M25.569

Pain in right knee Pain in left knee Pain in unspecified knee

Occipital Neuralgia

ICD-9 ICD-10

723.8 Other syndromes affecting cervical region

M53.81 M53.82 M53.83 M54.81

Other specified dorsopathies, occipito-atlanto-axial region Other specified dorsopathies, cervical region Other specified dorsopathies, cervicothoracic region Occipital neuralgia

Neck Pain

ICD-9 ICD-10

723.1 Cervicalgia M54.2 Cervicalgia




Clinical Example

CHIEF COMPLAINT: Right lower extremity pain, back pain, and neck pain. HISTORY OF PRESENT ILLNESS: Ms. XYZ is a 76-year-old resident of ASDF. She is seen at the request of Dr. ABC. She carries a diagnosis of pain in lower leg, occipital neuralgia, and neck pain. She underwent an L3-4 decompression in December of 2013 by Dr. Johnson for back and bilateral lower leg pain. Shortly after surgery, she began having pain in the right knee and is seen today with an outside lumbar MRI only. I have a report of a lumbar CT myelogram as well, but no films. She has occipital neuralgia and neck pain. She has a foraminal disc protrusion on the right, as well as a severely degenerated disc at L3-4. The patient complains essentially of pain along the dorsopathies, cervical region which is burning, shooting, aching and constant in nature. It is worse with standing and walking. She can walk about a block before her symptoms become debilitating. She is more comfortable in recumbency. She denies bowel or bladder dysfunction, saddle area hypoesthesia, numbness, tingling, weakness or Valsalva related exacerbation. She rates her pain as 9/10 in average and her daily level of intensity and 5/10 for her least level of pain. Alleviating factors include sitting, recumbency, sleeping, and massage. She treats her pain with Tylenol currently. REVIEW OF SYSTEMS: A complete review of systems was surveyed and is otherwise negative. The patient denies any other constitutional symptom. PHYSICAL EXAMINATION: Temp 97.7, pulse 78, BP 143/80. The patient walks with a slight forward stooped gait. There is no spasticity or ataxia. She has mild antalgia after a few steps to the right lower extremity. She has limited lumbar flexion, lumbar extension and right ipsilateral bending with provocable right leg pain. Lungs are clear to auscultation. Heart has regular rate and rhythm with normal S1, S2. No murmurs, rubs, or gallops. The abdomen is obese, nontender, nondistended without palpable organomegaly or pulsatile masses. The skin is warm and dry to touch. There is no cyanosis, clubbing, or edema. Degenerative changes are noted in the joints of the hands, knees and ankles. IMPRESSION: 1. Lower leg pain 2. Occipital neuralgia 3. Neck pain PLAN: The risks and benefits of right L4 selective nerve root block were discussed in detail with the patient and they include failure of pain relief, need for further procedures, infection, bleeding, damage to the spinal nerves or abdominal viscera, and postdural puncture headaches. She wished to proceed.




Coding

ICD-9 ICD-10

719.46 723.8 723.1

Pain in joint in lower leg Other syndromes affecting cervical region Cervicalgia

M25.561 M53.82 M54.2

Pain in right knee Other specified dorsopathies, cervical region Cervicalgia

Documentation for Pain in Joint will need to specify:

Laterality o Right o Left o Bilateral

Location o Upper o Lower

Documentation for Occipital Neuralgia will need to specify:

Region

Occipito-atlanto-axial

Cervical

Cervicothoracic

Other There are no additional documentation requirements for Neck Pain.




Case 9 - Sacroiliac Joint Syndrome

Sacroiliac Joint Syndrome

ICD-9 ICD-10

720.2 Sacroiliitis, not elsewhere classified

M46.1 Sacroiliitis, not elsewhere classified

Clinical Example

PROCEDURE: Sacroiliac Joint Injection Informed consent was obtained from the patient. The patient was placed in the prone position. After preparation, local anesthetic administration, and image intensifier control, a 25 gauge spinal needle was directed into the inferior aspect of the sacroiliac joint using a posterior approach. A small amount of contrast material was administered to outline the recesses of the joints. Verification of the initial needle position with contrast administration, 1 mL of solution was administered at this site after aspiration, consisting of 0.5 mL of 0.25% Marcaine and 0.5 mL of Celestone. Post-procedure, the needles were withdrawn and dressing was applied. Post-procedure no complications were noted.

Coding

ICD-9 ICD-10

720.2 Sacroiliitis, not elsewhere classified

M46.1 Sacroiliitis, not elsewhere classified

ICD-10 CM does not require any additional documentation for Sacroiliac.




Case 10 - Tenosynovitis of Hand and Wrist

Tenosynovitis of Hand and Wrist

ICD-9 ICD-10

727.05 Other tenosynovitis of hand and wrist

M65.831 M65.832 M65.839 M65.841 M65.842 M65.849

Other synovitis and tenosynovitis, right forearm Other synovitis and tenosynovitis, left forearm Other synovitis and tenosynovitis, unspecified forearm Other synovitis and tenosynovitis, right hand Other synovitis and tenosynovitis, left hand Other synovitis and tenosynovitis, unspecified hand




Clinical Example

POSTOPERATIVE DIAGNOSES 1. Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level. 2. Left carpal tunnel syndrome.

PROCEDURE: Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers ANESTHESIA: Local plus IV sedation (MAC). PROCEDURE DETAIL: Patient brought to the operating room. After induction of IV, sedation of the left hand was anesthetized suitable for carpal tunnel release; 10 cc of a mixture of 1% Xylocaine and 0.5% Marcaine was injected in the distal forearm and proximal palm suitable for carpal tunnel surgery. Routine prep and drape was employed. Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet and tourniquet inflated to 250 mmHg pressure. Hand was positioned palm up in the lead hand-holder. A short curvilinear incision about the base of the thenar eminence was made. Skin was sharply incised. Sharp dissection was carried down to the transverse carpal ligament and this was carefully incised longitudinally along its ulnar margin. Care was taken to divide the entire length of the transverse retinaculum including its distal insertion into deep palmar fascia in the midpalm. Proximally the antebrachial fascia was released for a distance of 2-3 cm proximal to the wrist crease to insure complete decompression of the median nerve. Retinacular flap was retracted radially to expose the contents of the carpal canal. Median nerve was identified, seen to be locally compressed with moderate erythema and mild narrowing. Locally adherent tenosynovitis right forearm was present and this was carefully dissected free. Additional tenosynovium was dissected from the flexor tendons, individually stripping and peeling each tendon in sequential order so as to debulk the contents of the carpal canal. Epineurotomy and partial epineurectomy were carried out on the nerve in the area of mild constriction to relieve local external scarring of the epineurium. When this was complete retinacular flap was laid loosely in place over the contents of the carpal canal and skin only was closed with interrupted 5-0 nylon horizontal mattress sutures. A syringe with 3 cc of Kenalog-10 and 3 cc of 1% Xylocaine using a 25 gauge short needle was then selected; 1 cc of this mixture was injected into the third finger A1 and A2 pulley tendon sheaths using standard trigger finger injection technique; 1 cc was injected into the fourth finger A1/A2 pulley tendon sheath using standard tendon sheath injection technique. Routine postoperative hand dressing with well-padded, well-molded volar plaster splint and lightly compressive Ace wrap was applied. Tourniquet was deflated. Good vascular color and capillary refill were seen to return to the tips of all digits. Patient discharged to the ambulatory recovery area and from there discharged home. Discharge medication is Darvocet-N 100, 30 tablets, one to two PO q.4h. p.r.n. Patient asked to begin gentle active flexion, extension and passive nerve glide exercises beginning 24-48 hours after surgery. She was asked to keep the dressings clean, dry, and intact and follow-up in my office.




Coding

ICD-9 ICD-10

727.05 Other tenosynovitis of hand and wrist

M65.831

Other synovitis and tenosynovitis, right forearm


• Laterality (right or left) • Forearm • Hand




Case 11 - Lumbar Radiculopathy and Back Pain

Lumbar Radiculopathy

ICD-9 ICD-10

724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified

M51.14 M51.15 M51.16 M51.17 M54.14 M54.15 M54.16 M54.17

Intervertebral disc disorders with radiculopathy, thoracic region Intervertebral disc disorders with radiculopathy, thoracolumbar region Intervertebral disc disorders with radiculopathy, lumbar region Intervertebral disc disorders with radiculopathy, lumbosacral region Radiculopathy, thoracic region Radiculopathy, thoracolumbar region Radiculopathy, lumbar region Radiculopathy, lumbosacral region

Back Pain

ICD-9 ICD-10

724.5

Unspecified backache M54.89 M54.9 M54.5

Other dorsalgia Dorsalgia, unspecified Low back pain




Clinical Example

PROCEDURE: Placement of intrathecal catheter for trial for permanent Medtronic SynchroMed pump. POST OPERATIVE DIAGNOSIS: Lumbar radiculopathy and back pain The patient is a 65 year old woman with lumbar radiculopathy (lumbar region) and low back pain with a history of three prior lumbar spine surgeries. She is well known to me from multiple prior therapeutic attempts with mixed success. She has failed oral narcotic therapy because the drugs make her dizzy, disoriented and itchy. Physical exam was performed for the patient’s admission to the hospital. Detailed consent was obtained, and the patient agreed to proceed. Patient was placed in the prone position on the C-arm fluoroscopy table. Cerebrospinal fluid emerged from the tip of the catheter. 1.2 mg of preservative-free morphine was injected. The catheter was secured with benzoin and a Biopatch dressing. The patient will be followed for the next two to three days in the hospital on a continuous intrathecal morphine infusion.

Coding

ICD-9 ICD-10

724.4 724.5

Thoracic or lumbosacral neuritis or radiculitis, unspecified Unspecified, backache

M54.16 M54.5

Radiculopathy, lumbar region Low back pain

Documentation for Lumbar Radiculopathy will need to specify:

• Region o Thoracic

o Thoracolumbar

o Lumbosacral

o Intervertebral

Documentation for Back Pain will need to specify:

• Type o Dorsalgia

o Other




Case 12 - Inflammatory Spondylitis and Left Sciatica

Inflammatory Spondylitis

ICD-9 ICD-10

720.9 Unspecified inflammatory spondylopathy

M46.90 M46.91 M46.92 M46.93 M46.94 M46.95 M46.96 M46.97 M46.98 M46.99

Unspecified inflammatory spondylopathy, site unspecified Unspecified inflammatory spondylopathy, occipito-atlanto-axial region Unspecified inflammatory spondylopathy, cervical region Unspecified inflammatory spondylopathy, cervicothoracic region Unspecified inflammatory spondylopathy, thoracic region Unspecified inflammatory spondylopathy, thoracolumbar Unspecified inflammatory spondylopathy, lumbar region Unspecified inflammatory spondylopathy, lumbosacral Unspecified inflammatory spondylopathy, sacral and sacrococcygeal region Unspecified inflammatory spondylopathy, multiple sites in spine

Sciatica

ICD-9 ICD-10

724.3 Sciatica M54.30 M54.31 M54.32

Sciatica, unspecified side Sciatica, right side Sciatica, left side




Clinical Example

DIAGNOSIS: Inflammatory Spondylitis and Left Sciatica. ANESTHESIA: Intravenous sedation NAME OF OPERATION: 1. Left L5-S1 transforaminal epidural steroid block with fluoroscopy. 2. Left L4-5 transforaminal epidural steroid block with fluoroscopy. 3. Monitored intravenous Versed sedation. PROCEDURE: Patient is here in hopes of achieving relief for inflammatory spondylopathy, lumbar region and sciatica of the left side. The patient was taken

to the block room. He was placed prone on the fluoroscopy table. He was monitored appropriately. He was administered Versed 2 mg IV. His O2 saturation remained greater than 90%. His back was prepped and draped. The C-arm was brought in. The endplates at L5-S1 were squared off. The C-arm was rotated to the left. The L5 pedicle, the superior articular process of the L5-S1 facet, and the "neck of the scotty dog" were all visualized. After adequate local anesthesia, a 22-gauge, 3-1/2-inch spinal needle was inserted using down-the-barrel-of-the-needle technique. The needle was advanced into the posterior aspect of the foramen and then advanced anteriorly toward the 6 o'clock position on the pedicle. No paresthesias were noted. One-half cc of contrast was injected and spread medially around the pedicle and into the epidural space, and the L5 nerve root was visualized. Depo-Medrol 80 mg plus 1 cc of 4% preservative-free lidocaine was injected. The needle was flushed and removed.

Coding

ICD-9 ICD-10

720.9 724.3

Unspecified inflammatory spondylopathy Sciatica

M54.30 M54.32

Unspecified inflammatory spondylopathy, lumbar region Sciatica, left side




Documentation for Inflammatory Spondylopathy will need to specify:

• Region

o Occipito-atlanto-axial region

o Cervical region o Cervicothoracic region

o Thoracic region o Thoracolumbar

o Lumbar region o Lumbosacral o Sacral and sacrococcygeal region o Multiple sites in spine

Documentation for Sciatica will need to specify:

• Laterality (right or left)




Case 13 - Spinal Stenosis

Spinal Stenosis

ICD-9 ICD-10

724.02 Spinal stenosis of lumbar region, without neurogenic claudication

M48.00 M48.01 M48.02 M48.03 M48.04 M48.05 M48.06 M48.07 M48.08

Spinal stenosis, site unspecified Spinal stenosis, occipito-atlanto-axial region Spinal stenosis, cervical region Spinal stenosis, cervicothoracic Spinal stenosis, thoracic region Spinal stenosis, thoracolumbar Spinal stenosis, lumbar Spinal stenosis, lumbosacral region Spinal stenosis, sacral and sacrococcygeal region

Clinical Example

DIAGNOSIS: Severe spinal stenosis ANESTHESIA: General PROCEDURE: 1. Implantation of intraspinal catheter 2. Implantation of intraspinal pump INDICATION FOR PROCEDURE: The patient is here today for implantation of an intraspinal morphine pump. The patient failed previous oral narcotics for issues of side effects and complications for severe spinal stenosis of the thoracolumbar region. DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was taken to the operating room. The patient was placed in a lateral decubitus position. The area over the back, flank and abdomen was prepped with Betadine and draped in a standard sterile fashion. A two-inch incision was made over the L3 to L5 vertebral bodies, dissected down to the posterior spinous ligament. A 15-gauge intraspinal needle was introduced into the arachnoid space with return of clear fluid. Medtronic catheter, #8703, was advanced through the needle under fluoroscopic guidance of approximately 2-1/2 to 3 vertebral segments. A small pocket was then made just to the side of the midline incision subcutaneously. On the abdomen, an incision was then made at about the level of the umbilicus but more lateral. The incision was extended to about 3-1/2 to 4 inches to accommodate the pump. The pump was thus secured into the pocket. The wound was then closed with #0 Vicryl subcutaneously and 5-0 nylon on the surface. The patient was taken to recovery in satisfactory condition.




Coding

ICD-9 ICD-10


M48.05 Spinal stenosis, thoracolumbar

Documentation for Spinal Stenosis will need to specify:

• Region

o Occipito-atlanto-axial region

o Cervical region

o Cervicothoracic

o Thoracic

o Thoracolumbar

o Sacral and sacrococcygeal




Case 14 - Spondylolisthesis

Spondylolisthesis

ICD-9 ICD-10

756.12 Congenital spondylolisthesis Q76.2 Congenital spondylolisthesis

Clinical Example

DIAGNOSIS: Congenital spondylolisthesis PROCEDURE PERFORMED: Fluoroscopic interlaminar L4-L5 lumbar epidural steroid injection DESCRIPTION OF PROCEDURE: Detailed consent was obtained for fluoroscopic interlaminar epidural steroid injection. The patient has agreed to proceed with the injection for congenital spondylolisthesis. The patient was placed in the prone position on the C-arm fluoroscopy table. The lumbar area was prepped and draped in the usual sterile fashion using Betadine. A 25 gauge skin wheal using 1% Xylocaine was placed in the skin overlying the right L4-L5 epidural space. A mixture of Xylocaine 1% 4cc and Depo-Medrol 80mg was injected without difficulty. The patient tolerated the procedure well and was discharged in approximately an hour with full recovery of sensory and motor function.

Coding

ICD-9 ICD-10

756.12 Congenital spondylolisthesis Q76.2 Congenital spondylolisthesis


• Congenital or acquired




Case 15 - Abdominal Pain

Abdominal Pain

ICD-9 ICD-10

789.00 Abdominal pain R10.10 R10.11 R10.12 R10.13 R10.30 R10.31 R10.32 R10.33

Upper abdominal pain, unspecified Right upper quadrant pain Left upper quadrant pain Epigastric pain Lower abdominal pain, unspecified Right lower quadrant pain Left lower quadrant pain Periumbilical

Clinical Example

DIAGNOSIS: Chronic abdominal pain PROCEDURE PERFORMED: Celiac Plexus Block ANESTHESIA: Local/IV sedation COMPLICATIONS: None DESCRIPTION OF PROCEDURE: The procedure is being performed in hopes of relief for chronic abdominal pain in upper abdomen and right lower quadrant. The patient was placed in the prone position. Back prepped and draped in sterile fashion. Then 1.5% of Lidocaine for skin wheal was made approximately 10 cm lateral to the L1-L2 vertebral junction. A 20 gauge, 15 cm needle was then placed in a cephalad medial 45degree direction; the tip of the needle was just inside the L1 vertebral body. On lateral view, this was noted to be approximately 1.5-2.5 cm anterior to the vertebral body. At this time, 3 cc of Omnipaque dye was injected to the opposite side where the same sequence was performed. Following this, a mixture of 18 cc of 0.5% Marcaine was injected on each side. Neosporin and Band-Aids were applied over the puncture sites. The patient was taken to the outpatient recovery where blood pressure was monitored and fluids given as needed. The patient was discharged to operating room recovery in stable condition.

ICD-9 ICD-10

789.00 Abdominal pain R10.10

R10.31

Upper abdominal pain, unspecified

Right upper quadrant pain




Documentation for Abdominal Pain will need to specify:

• Location

o Upper

o Right upper

o Left upper

o Epigastric

o Lower abdomen

o Right abdomen

o Left lower abdomen

o Periumbilical




Case 16 - Pain in Limb

Pain in Limb

ICD-9 ICD-10

729.5

Pain in limb M79.601 M79.602 M79.603 M79.604 M79.605 M79.606 M79.609 M79.621 M79.622 M79.629 M79.631 M79.632 M79.639 M79.641 M79.642 M79.643 M79.644 M79.645 M79.646 M79.651 M79.652 M79.659 M79.661 M79.662 M79.669 M79.671 M79.672 M79.673 M79.674 M79.675 M79.676

Pain in right arm Pain in left arm Pain in arm, unspecified Pain in right leg Pain in left leg Pain in leg, unspecified Pain in unspecified limb Pain in right upper arm Pain in left upper arm Pain in unspecified upper arm Pain in right forearm Pain in left forearm Pain in unspecified forearm Pain in right hand Pain in left hand Pain in unspecified hand Pain in right finger(s) Pain in left finger(s) Pain in unspecified finger(s) Pain in right thigh Pain in left thigh Pain in unspecified thigh Pain in right lower leg Pain in left lower leg Pain in unspecified lower leg Pain in right foot Pain in left foot Pain in unspecified foot Pain in right toe(s) Pain in left toe(s) Pain in unspecified toe(s)




Documentation Example - Pain in Limb

Clinical Example

Michele is here for initial evaluation of her right thumb pain. Approximately one year

ago, she was bitten by a dog and had to have stitches which she received in ER.

Today she comes in and states she has a bone spur that feels like it is going to pop

out of her hand.

Plan: Right thumb pain and acquired trigger finger. I discussed the option of a

cortisone injection today. Overall, patient is doing well, conservative treatment splint

vs. cortisone injection and patient refuses injection at this time.

Coding

ICD-9 ICD-10

729.5 Pain in limb M79.644 Pain in right finger(s)

727.03 Trigger finger acquired M65.311 Trigger thumb, right thumb




Clinical Example

The patient is a 44-year-old man who was seen for complaints of low back and

bilateral leg pain. Most recently he was working at Taco Bell, when he had an

occurrence of back pain, and he was seen in our clinic on 04/12/05. He rated pain of

8/10.

He took a Medrol Dosepak and states that his pain level has decreased to 4-5/10. Pain

is between L4 and the sacrum. Vital signs: BP 158/86, R 14, P 60, T 100.2. Lumbar

spine is minimally tender to palpation. His ROM is estimated at 40 degrees of flexion

and 15 degrees of extension. Straight leg raises elicit minimal leg pain bilaterally.

Lower extremity reflexes are symmetric.

IMP: Low back pain with bilateral leg pain. His pain level has improved.

PLAN: The patient will take another Medrol Dosepak. He can continue with PT and continue with the same lifting restrictions. F/U is within one week.

Coding

ICD-9 ICD-10

724.2 Lumbago M54.5 Lumbago

729.5 Pain in Limb M79.604

M79.605

Pain in right leg

Pain in left leg

Documentation required for Pain in Limb includes:

• Laterality o Right/left o Bilateral

• Specific limb

o Arm o Leg o Forearm o Hand o Finger(s) o Thigh o Lower leg o Foot o Toe(s)




Case 17 - Chronic Pain

Chronic Pain Due to Trauma

ICD-9 ICD-10

338.21 Chronic pain due to trauma G89.21

G89.22

G89.28

G89.29

Chronic pain due to trauma

Chronic post-thoracotomy pain

Other chronic post-procedural pain

Other chronic pain

Clinical Example

A 90-year old woman comes in complaining of chronic pain in her left hip. She is

unable to bear weight on her left leg. She fell from the left side of her bed while

resting. This happened 3 months ago and she still is experiencing severe pain.

This happened while she was at the nursing home. This is the second time this

has happened. A hip x-ray was taken and no fracture was detected.

The patient was released back to the nursing home.

Coding

ICD-9 ICD-10

338.21 959.6 E884.4

Chronic pain due to trauma Injury, other and unspecified hip and thigh Accidental fall from bed

G89.21 S79.912D Y93.84 Y92.122 W06.XXXD

Chronic pain due to trauma Unspecified injury of left hip, subsequent encounter Activity, sleeping Bedroom in nursing home as the place of occurrence Fall from bed, subsequent encounter

Documentation required for Chronic Pain Due to Trauma will need to include:

Type o Chronic o Post-thoracotomy o Post-procedure o Other




Case 18 - Lumbar Intervertebral Disc without Myelopathy

Lumbar Intervertebral Disc without Myelopathy

ICD-9 ICD-10

722.10 Lumbar intervertebral disc without myelopathy

M51.24 M51.25 M51.26 M51.27

Other intervertebral disc displacement, thoracic region Other intervertebral disc displacement, thoracolumbar region Other intervertebral disc displacement, lumbar region Other intervertebral disc displacement, lumbosacral region

Clinical Example

The patient is a 33-year-old Caucasian female who had 2 prior lumbar laminectomy

surgeries at L5-S1 (the bottom level of the spine). Her leg pain improved after these two

spinal operations, but her low back pain increased due to progressive collapse of the L5-

S1 intervertebral disc. She tried three years of conservative therapy all of which failed to

relieve her ongoing low back pain. A subsequent pregnancy increased the stress on her

lumbar spine and made the low back pain significantly worse.

The patient presents today to discuss options going forward. After spending

approximately 45 minutes going over several options, the patient has decided to

proceed with a disc replacement surgery.

Impression/Plan: Intervertebral disc displacement, lumbar region




Coding

ICD-9 ICD-10

722.10 Lumbar intervertebral disc

without myelopathy

M51.26 Other intervertebral disc

displacement, lumbar region

Documentation required for Lumbar Intervertebral Disc without Myelopathy includes:

• Type o With or without myelopathy or radiculopathy o Region o Thoracic o Thoracolumbar o Lumbar o Lumbosacral




Case 19-Displacement of Cervical Intervertebral Disc without Myelopathy

Displacement of Cervical Intervertebral Disc without Myelopathy

ICD-9 ICD-10

722.0

Displacement of cervical intervertebral disc without myelopathy

M50.20 M50.21 M50.22 M50.23

Other cervical disc displacement, unspecified cervical region Other cervical disc displacement, high cervical region Other cervical disc displacement, mid cervical region Other cervical disc displacement, cervicothoracic region

Clinical Example

The patient arrives to the office today to follow-up on treatment of his cervical C5-C6

(mid-cervical region) disc displacement. Jon has had spondylosis (degenerative

osteoarthritis) of the cervical region for a number of years and just recently

diagnosed with C5-C6 cervical disc displacement. Last month we started Jon on anti-

inflammatory and today I would like to check on his progress.

Impression: Cervical disc displacement (C5-C6); Spondylosis (degenerative

osteoarthritis) of the cervical region

Will continue this patient on anti-inflammatory, as well as ice/heat and massage. Jon is to return to clinic in 1 month.




Coding

ICD-9 ICD-10

722.0 715.90

Displacement of cervical intervertebral disc without myelopathy Osteoarthritis, unspecified whether generalized or localized, unspecified site

M50.22 M47.812

Other cervical disc displacement, mid cervical region Spondylosis w/o myelopathy or radiculopathy, cervical region

Documentation required for Displacement of Cervical Intervertebral Disc without

Myelopathy includes:

• Type o Region o High o Mid o Cervicothoracic




Case 20 - Lumbar Sprain

Lumbar Sprain

ICD-9 ICD-10

847.2 Lumbar sprain and strain S33.5XXA S33.5XXD S33.5XXS

Sprain of ligaments of lumbar spine, initial encounter Sprain of ligaments of lumbar spine, subsequent encounter Sprain of ligaments of lumbar spine, sequela

In ICD-10, the appropriate 7th character is to be added to each code from category S33.

A

D

S

Initial encounter

Subsequent

encounter

Sequela

Clinical Example

Mrs. Smith is seen today for complaint of a lumbar sprain, initial encounter which is

causing intense pain. Her pain is worse with sitting, standing, and is essentially worse

in the supine position. She states her right shoulder pain is constant on the anterior

lateral aspect and radiates down into the bicep area. She denies associated bowel or

bladder dysfunction, saddle area hypoesthesia, or falls. She has treated her back

symptoms with heat and ice, but would like physical therapy as well.

She is intolerant to any type of anti-inflammatory medications and has a number of

allergies to multiple medications. Her pain is described as constant, aching, and on a

scale of 1-10, pain is a 7.

Images for cervical and lumbar spine will be ordered. F/U in 2 weeks for results and possible options pending results.




Coding

Documentation required for Lumbar Sprain includes:

Encounter o Initial o Subsequent o Sequela

Documentation required for pain in joint:

Location (anatomy)

Laterality

ICD-9 ICD-10

847.2 719.41

Lumbar sprain and strain Pain in joint, shoulder region

S33.5XXA M25.511

Sprain of ligaments of lumbar spine, initial encounter Right shoulder pain




Case 21 - Spinal Stenosis of Lumbar Region, Without Neurogenic Claudication

Spinal Stenosis of Lumbar Region, Without Neurogenic Claudication

ICD-9 ICD-10


M48.00 M48.01 M48.02 M48.03 M48.04 M48.05 M48.06 M48.07 M48.08

Spinal stenosis, site unspecified Spinal stenosis, occipito-atlanto-axial region Spinal stenosis, cervical region Spinal stenosis, cervicothoracic region Spinal stenosis, thoracic region Spinal stenosis, thoracolumbar region Spinal stenosis, lumbar region Spinal stenosis, lumbosacral region Spinal stenosis, sacral and sacrococcygeal region

Clinical Example

Patient presents for follow-up on spinal stenosis. She has been doing well and has no

additional complaints.

Impression: Lumbar spinal stenosis.

Patient to return to clinic in 3 months or sooner as needed and to continue current regimen.

Coding

ICD-9 ICD-10

724.02 Spinal stenosis of lumbar

region, without neurogenic

claudication

M48.06 Spinal stenosis, lumbar region




Documentation requirements for Spinal Stenosis of Lumbar Region include:

Region o Occipito-atlanto-axial

o Cervical region

o Cervicothoracic

o Thoracic region

o Thoracolumbar region

o Lumbar region

o Lumbosacral region

o Sacral

o Sacrococcygeal




Case 22 - Cervical Radiculopathy

Cervical Radiculopathy

ICD-9 ICD-10

723.4 Brachial neuritis or radiculitis NOS

M54.10 M54.11 M54.12 M54.13 M54.14 M54.15 M54.16 M54.17 M54.18

Radiculopathy, site unspecified Radiculopathy, occipito-atlanto-axial region Radiculopathy, cervical region Radiculopathy, cervicothoracic region Radiculopathy, thoracic region Radiculopathy, thoracolumbar Radiculopathy, lumbar region Radiculopathy, lumbosacral Radiculopathy, sacral and sacrococcygeal region

Clinical Example

Patient is seen with sudden onset of severe pain in the muscles of the cervical

region and frequently the arm and neck. Numbness and muscle weakness also

mentioned. No shortness of breath.

On exam the arm muscles had decreased reflexes and the shoulder had decreased

sensation.

IMPRESSION: Radiculopathy, cervical region.

Plan: Nerve conduction studies ordered and x-ray of shoulder. Patient was prescribed Percocet. Follow-up in 1 week.




Coding

ICD-9 ICD-10

723.4 Brachial neuritis or radiculitis

NOS

M54.12 Radiculopathy, cervical region

Documentation Example - Cervical Radiculopathy

Documentation required for Cervical Radiculopathy will need to include:

Region o Occipito-atlanto-axial o Cervical o Cervicothoracic o Thoracic o Thoracolumbar o Lumbar o Lumbosacral o Sacral and sacrococcygeal




Case 23 - Spinal Stenosis of Lumbar Region, Without Neurogenic Claudication

Spinal Stenosis of Lumbar Region, Without Neurogenic Claudication

ICD-9 ICD-10


M48.00 M48.01 M48.02 M48.03 M48.04 M48.05 M48.06 M48.07 M48.08

Spinal stenosis, site unspecified Spinal stenosis, occipito-atlanto-axial region Spinal stenosis, cervical region Spinal stenosis, cervicothoracic region Spinal stenosis, thoracic region Spinal stenosis, thoracolumbar region Spinal stenosis, lumbar region Spinal stenosis, lumbosacral region Spinal stenosis, sacral and sacrococcygeal region

Clinical Example

Patient presents for follow-up on spinal stenosis. She has been doing well and has no

additional complaints.

Impression: Lumbar spinal stenosis.

Patient to return to clinic in 3 months or sooner as needed and to continue current regimen.




Coding

Documentation requirements for Spinal Stenosis of Lumbar Region include:

Region o Occipito-atlanto-axial

o Cervical region

o Cervicothoracic

o Thoracic region

o Thoracolumbar region

o Lumbar region

o Lumbosacral region

o Sacral

o Sacrococcygeal

ICD-9 ICD-10

724.02 Spinal stenosis of lumbar

region, without neurogenic

claudication

M48.06 Spinal stenosis, lumbar region




Case 24 - Cervical Disc Degeneration

ICD-9-CM ICD-10-CM

722.0 722.4

Cervical disc displacement without myelopathy Degeneration of cervical intervertebral disc

M50.00 M50.01 M50.02 M50.03 M50.10 M50.11 M50.12 M50.13 M50.20 M50.21 M50.22 M50.23

Cervical disc disorder with myelopathy, unspecified cervical region Cervical disc disorder with myelopathy, high cervical region Cervical disc disorder with myelopathy, mid cervical region Cervical disc disorder with myelopathy, cervicothoracic region Cervical disc disorder with radiculopathy, unspecified cervical region Cervical disc disorder with radiculopathy, high cervical region Cervical disc disorder with radiculopathy, mid-cervical region Cervical disc disorder with radiculopathy, cervicothoracic region Other cervical disc displacement, unspecified cervical region Other cervical disc displacement, high cervical region Other cervical disc displacement, mid cervical region Other cervical disc displacement, cervicothoracic region




Cervical Disc Degeneration (con’t)

ICD-9-CM ICD-10-CM

722.0 722.4


M50.30 M50.31 M50.32

Other cervical disc degeneration, unspecified cervical region Other cervical disc degeneration, high cervical region Other cervical disc degeneration, mid cervical region

Clinical Example

Chief Complaint: “My neck hurts and I have a tingling pain sensation going down my right arm.” Patient is a 68 year-old male with history of neck pain that has been worsening over the last two years. Recently, he has experienced some numbness and a painful tingling sensation in his right arm going down to his thumb. No other symptoms or pertinent medical history. Review of systems is negative except for the neck pain and sensations in his right arm described above. No history of acute injury to neck or arm. Physical exam is normal except for neurological exam of the right upper extremity, which reveals slight decrease to sensation in the thumb and forefinger region of the hand in the C6 nerve root distribution. No evidence of weakness in the muscles of the arm or hand. MRI scan of the neck shows degenerative changes of the C5-6 disc with lateral protrusion of disc material. No other abnormalities noted. Assessment and Plan Cervical transforaminal injection at C5-6




Coding

Document requirements:

Type

Location

Region of spine o High o Mid o Cervicothoracic

Note: This is a combination code that includes the disc degeneration and radiculopathy.

ICD-9 ICD-10

722.0 722.4


M50.12 Cervical disc disorder with

radiculopathy, mid-cervical region




Case 25

ICD-9 ICD-10

486 Pneumonia J18.0 J18.1 J18.2 J18.8 J18.9

Bronchopneumonia, unspecified organism Lobar pneumonia, unspecified organism Hypostatic pneumonia, unspecified organism Other pneumonia, unspecified organism Pneumonia, unspecified organism

790.29 Other abnormal glucose R73.01 R73.02 R73.09

Impaired fasting glucose Impaired glucose tolerance (oral) Other abnormal glucose




Deep Vein Thrombosis, Lower Extremity

ICD-9 ICD-10 453.40 Acute venous embolism and

thrombosis of unspecified deep vessels of lower extremity

I82.401 I82.402 I82.403 I82.409 I82.411 I82.412 I82.413 I82.419 I82.421 I82.422 I82.423 I82.429 I82.431 I82.432 I82.433 I82.439 I82.441 I82.442 I82.443 I82.449

Acute embolism and thrombosis of unspecified deep veins of right lower extremity Acute embolism and thrombosis of unspecified deep veins of left lower extremity Acute embolism and thrombosis of unspecified deep veins of bilateral lower extremity Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity Acute embolism and thrombosis of right femoral vein Acute embolism and thrombosis of left femoral vein Acute embolism and thrombosis of bilateral femoral vein Acute embolism and thrombosis of unspecified femoral vein Acute embolism and thrombosis of right iliac vein Acute embolism and thrombosis of left iliac vein Acute embolism and thrombosis of bilateral iliac vein Acute embolism and thrombosis of unspecified iliac vein Acute embolism and thrombosis of right popliteal vein Acute embolism and thrombosis of left popliteal vein Acute embolism and thrombosis of bilateral popliteal vein Acute embolism and thrombosis of unspecified popliteal vein Acute embolism and thrombosis of right tibial vein Acute embolism and thrombosis of left tibial vein Acute embolism and thrombosis of bilateral tibial vein Acute embolism and thrombosis of unspecified tibial vein




Deep Vein Thrombosis (Continued)

ICD-9 ICD-10 453.40 Acute venous embolism and

thrombosis of unspecified deep vessels of lower extremity

I82.491 I82.492 I82.493 I82.499 I82.4Y1 I82.4Y2 I82.4Y3 I82.4Y9 I82.4Z1 I82.4Z2 I82.4Z3 I82.4Z9 I82.501 I82.502 I82.503

Acute embolism and thrombosis of other specified deep vein of right lower extremity Acute embolism and thrombosis of other specified deep vein of left lower extremity Acute embolism and thrombosis of other specified deep vein of bilateral lower extremity Acute embolism and thrombosis of other specified deep vein of unspecified lower extremity Acute embolism and thrombosis of unspecified deep veins of right proximal lower extremity Acute embolism and thrombosis of unspecified deep veins of left proximal lower extremity Acute embolism and thrombosis of unspecified deep veins of bilateral proximal lower extremity Acute embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity Acute embolism and thrombosis of unspecified deep veins of right distal lower extremity Acute embolism and thrombosis of unspecified deep veins of left distal lower extremity Acute embolism and thrombosis of unspecified deep veins of bilateral distal lower extremity Acute embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity Chronic embolism and thrombosis of unspecified deep veins of right lower extremity Chronic embolism and thrombosis of unspecified deep veins of left lower extremity Chronic embolism and thrombosis of unspecified deep veins of bilateral lower extremity




Deep Vein Thrombosis, Lower Extremity (continued)

ICD-9 ICD-10

453.40 Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity

I82.509 I82.511 I82.512 I82.513 I82.519 I82.521 I82.522 I82.523 I82.529 I82.531 I82.532 I82.533 I82.539 I82.541 I82.542 I82.543 I82.549 I82.591 I82.592 I82.593

Chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity Chronic embolism and thrombosis of right femoral vein Chronic embolism and thrombosis of left femoral vein Chronic embolism and thrombosis of bilateral femoral vein Chronic embolism and thrombosis of unspecified femoral vein Chronic embolism and thrombosis of right iliac vein Chronic embolism and thrombosis of left iliac vein Chronic embolism and thrombosis of bilateral iliac vein Chronic embolism and thrombosis of unspecified iliac vein Chronic embolism and thrombosis of right popliteal vein Chronic embolism and thrombosis of left popliteal vein Chronic embolism and thrombosis of bilateral popliteal vein Chronic embolism and thrombosis of unspecified popliteal vein Chronic embolism and thrombosis of right tibial vein Chronic embolism and thrombosis of left tibial vein Chronic embolism and thrombosis of bilateral tibial vein Chronic embolism and thrombosis of unspecified tibial vein Chronic embolism and thrombosis of other specified deep vein of right lower extremity Chronic embolism and thrombosis of other specified deep vein of left lower extremity Chronic embolism and thrombosis of other specified deep vein of bilateral lower extremity




Deep Vein Thrombosis (Continued)

ICD-9 ICD-10

453.40 Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity

I82.599 I82.5Y1 I82.5Y2 I82.5Y3 I82.5Y9 I82.5Z1 I82.5Z2 I82.5Z3 I82.5Z9

Chronic embolism and thrombosis of other specified deep vein of unspecified lower extremity Chronic embolism and thrombosis of unspecified deep veins of right proximal lower extremity Chronic embolism and thrombosis of unspecified deep veins of left proximal lower extremity Chronic embolism and thrombosis of unspecified deep veins of bilateral proximal lower extremity Chronic embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity Chronic embolism and thrombosis of unspecified deep veins of right distal lower extremity Chronic embolism and thrombosis of unspecified deep veins of left distal lower extremity Chronic embolism and thrombosis of unspecified deep veins of bilateral distal lower extremity Chronic embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity




Clinical Example

CHIEF COMPLAINT: Increased weakness and fever. HISTORY OF PRESENT ILLNESS: This is a 59-year-old white male with history of large hemispheric stroke two months ago. Since that time, the patient has been aphasic and difficult to ambulate with right sided weakness. Two days prior to presentation to the hospital, he started having some increased problems with coordination, some increased problems with weakness and therefore presented to the emergency department after the patient developed fever at home. MEDICATIONS AT HOME: Zoloft 100 mg daily. Senokot as needed for constipation. Aspirin 325 mg daily. Colace 100 mg daily as needed for constipation. PAST MEDICAL HISTORY: Significant for left sided cerebrovascular accident, left hemisphere, 2002. At that time, the patient was found to have complete left internal carotid occlusion, felt inoperable at that time. The patient also had a left fem-pop procedure back in 2013. The patient quit smoking and quit his chronic alcohol use when he had the stroke. The patient did not know his parents. The patient is retired. The patient lives with his son. The patient also has two other sons. REVIEW OF SYSTEMS: Difficult to get with the patient unable to talk. It is apparent based on my observation he has some left leg pain. PHYSICAL EXAMINATION: GENERAL/VITAL SIGNS: The patient was febrile with temperature of 102. The rest of the vital signs were stable. This is a well-developed, well-nourished white male who looks older than his stated age, in no acute distress. HEENT: The patient has no bruits, no thyromegaly, no lymphadenopathy. CHEST: The patient does have crackles at the bases, otherwise sounds clear. CARDIAC: Regular rate and rhythm without any murmurs heard. ABDOMEN: Benign, soft, positive bowel sounds, nontender, nondistended, no hepatosplenomegaly. EXTREMITIES: The patient has palpable pedal pulses but decreased, 1+ edema, greater on the right than the left, with chronic redness. The patient has developed stiffness of his right upper extremity. Keeping a closed fist is difficult. The patient does have some weakness here also.




Clinical Example (continued)

IMPRESSION AND PLAN: Admit as inpatient. 1. Pneumonia. I am concerned about aspiration with right upper lobe and left lower

lobe affected. The patient is on Zosyn, which is the appropriate antibiotic. We will

ask Speech also to do a swallowing study on this patient.

2. Hyperglycemia. This was never an issue before but patient was hyperglycemic on admission. We will check his blood sugars throughout the hospital course.

3. With his previous stroke, there is concern that the patient is using his right side even worse than before. We will obtain MRI of the patient to see if new thrombotic event has happened.

4. Deep venous thrombosis prophylaxis. We will use Lovenox.

Coding in ICD-10

ICD-9 ICD-10

486 Pneumonia J18.1

Lobar pneumonia, unspecified organism

790.29 Other abnormal glucose R73.09 Other abnormal glucose

453.40 Deep vein thrombosis I82.5Z9 Chronic embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity (Query)




Documentation Requirements

Deep Vein Thrombosis

Acute vs. chronic

Vein o Femoral vein o Iliac vein o Popliteal vein o Tibial vein

Laterality

Note: Code first, venous embolism and thrombosis complicating abortion, ectopic pregnancy (O00-O07; O08.7), pregnancy, childbirth, puerperium (O22.-, O87,-).

Note: Use additional code, if applicable, for associated long-term (current) use of anticoagulants (Z79.01).

Notes



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