Update To Coding Degenerative Changes
Guest blog by Monita Turpin, coding analyst at 3M Health Information Systems.
In my last blog, I wrote about the conundrum of assigning ICD-10-CM code when providers only document degenerative changes.
I wrote my blog in early June 2018. The day before my blog was published, I received notification of an updated Coding Clinic, Second Quarter ICD-10 2018 Page: 15 Effective with discharges: .
So, lets revisit the scenario with the clarification from Coding Clinic:
The provider documented degenerative changes of the left knee in the impression, and the clinical indication was left knee pain. What is the correct diagnosis code?
The question that was submitted to Coding Clinic was:
What is the correct code assignment for advanced degenerative changes of both hips when documented in the final impression section of an outpatient radiology report?
According to Coding Clinic: Assign code M16.0Bilateral primary osteoarthritis of hip for degenerative changes of hips.
Coding Clinics rationale is, ICD-10- CMs Alphabetic Index under Degeneration, joint disease instructs see Osteoarthritis.
This is a major change that some will say has not completely colored in the grey area for degenerative changes because the provider did not specify joint disease however, we must code based upon guidelines and when guidelines are not clear, we must go to Coding Clinic for guidance.
Monita Turpin is a coding analyst at 3M Health Information Systems.
Documentation For Icd 10 Code For Osteoarthritis
The documentation can have different names for osteoarthritis in the medical report. I being a medical coder, have come across phrases like degenerative changes of joint, degenerative joint disease, tricompartmental osteoarthritis, OA disease etc. which will be documented in the medical report to denote osteoarthritis. Hence, you should be careful while coding osteoarthritis ICD 10 CM code.
Read also: Best coding tips for Pregnancy complications in ICD codes
Basics About Osteoarthritis Icd 10 Code
Osteoarthritis is a joint disease caused by aging, injury or obesity. The most common symptoms for osteoarthritis are joint pain and stiffness. Therefore, coding Osteoarthritis is not much different from coding joint pain. I have already shared how we have code ICD 10 CM code for Knee pain in my previous post. As I have mentioned earlier, the ICD 10 code varies for each joint, so let us first checkout the different ICD 9 CM for Osteoarthritis of each joint.
715.91 shoulder
715.95 Pelvic region and thigh
715.96 Lower leg
715.97 ankle and foot
715.90 site, unspecified
Now, the above list of ICD 9 codes for osteoarthritis is to be used only when they have documented osteoarthritis. There are similar ICD 9 codes for localized and generalized osteoarthritis, which should be used only when there is clear documentation of localized and generalized osteoarthritis of joint.
Read also: Learn about the difference between Excludes 1 and Excludes 2 in ICD 10
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Clinical Documentation Tips For Orthopedists
Specifying anatomical location and laterality required by ICD-10 is easier than you think.
This detail reflects how physicians and clinicians communicate and to what they pay attention. It is a matter of ensuring the information is captured in your documentation.
In ICD-10-CM, there are three main categories of changes:
- Definition Changes
- Terminology Differences
- Increased Specificity
For orthopedics the focus is on increased specificity. Over 1/3 of the expansion of ICD-10 codes is due to the addition oflaterality . Physicians and other clinicians likely already note laterality when evaluating the clinically
Unilateral Primary Osteoarthritis Right Hipm1611
Chapter 13 – Diseases of the musculoskeletal system and connective tissue » Osteoarthritis » Unilateral primary osteoarthritis, right hip
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