ICD-10 Training: Detailing patient encounters

As physicians and coders transition to ICD-10-CM, several coding and documentation issues will need to be addressed related to musculoskeletal and connective tissue diseases.

For example, in ICD-10-CM, more specific site designations and laterality are components of many codes. Documentation of episode of care is required for pathological fractures. The documentation must also clearly differentiate acute traumatic conditions from conditions that are chronic or recurrent. New documentation requirements for intraoperative and post-procedural complications will necessitate a careful review of the new codes for these conditions, along with their current documentation.

There are more combination codes that capture two or more related conditions-the etiology and the manifestations of certain conditions; or a disease process and the common symptoms of the disease. Familiarity with the new combination codes is needed to ensure that documentation is sufficient to capture any related conditions, both the etiology and manifestation, and/or any related symptoms for the condition being reported.

In addition, some conditions have been reclassified, such as gout. A few examples of each of these general coding and documentation requirements related to diseases of the musculoskeletal system are provided here.

Site specificity
Site specificity is an important component of ICD-10-CM musculoskeletal system and connective tissue codes
Dorsopathies, which are conditions affecting the spine and intervertebral joints, provide a good example of site specificity. In ICD-10-CM, codes for ankylosis of the spine are found in subcategory M43.2-fusion of spine, and site is a component of the code.

To assign the most specific code, the site of the ankylosis must be identified as the occipito-atlanto-axial region (M43.21), cervical region (M43.22), cervicothoracic region (M43.23), thoracic region (M43.24), thoracolumbar region (M43.25), lumbar region (M43.26), lumbosacral region (M43.27), or sacral and sacrococcygeal region (M43.28).

In ICD-9-CM, ankylosis of the spine is reported with nonspecific codes. For example, ankylosis of the lumbosacral region is reported with the nonspecific code 724.6 Disorders of sacrum, while other sites of spinal ankylosis are reported with code 724.9 Other unspecified back disorders.

Laterality
Laterality is required for the vast majority of musculoskeletal and connective tissue diseases affecting the extremities.
For example, in ICD-10-CM, trigger finger is found in subcategory M65.3- and requires documentation of the specific finger affected, e.g., thumb, index finger, middle finger, ring finger, or little finger as well as laterality (right, left).

While there are also unspecified codes for trigger finger where the specific finger and laterality are not documented, these codes should not be used and may result in denial of payment because the affected finger and laterality should always be specified when treating. In ICD-9-CM, trigger finger is reported with the single code 727.03 Trigger finger (acquired).

In ICD-10-CM, bilateral codes are available for musculoskeletal and connective tissue diseases that often affect both sides of the body. For example, a specific code is available in ICD-10-CM for bilateral primary osteoarthritis of the knee (M17.0) as well as for primary osteoarthritis affecting only the right knee (M17.11) or left knee (M17.12).

Episode of care
Documentation of episode of care is required in ICD-10-CM for pathological fractures which include:

• fatigue fractures of the vertebra (M48.4-),

• collapsed vertebra (M48.5-),

• osteoporosis with pathological fracture (M80.-),

• stress fracture (M84.3-),

• pathologic fracture not elsewhere classified (M84.4-),

• pathological fracture in neoplastic disease (M84.5-), and

• pathologic fracture in other diseases (M84.6-).

For these conditions, a seventh character extension is required to identify the episode of care as an encounter for treatment of the acute condition, a subsequent encounter for aftercare, or care for a sequela (late effect) of the injury.

For fatigue fractures of the vertebrae and collapsed vertebrae, the available episode of care designations include:

• A: Initial encounter for fracture

• D: Subsequent encounter for fracture with routine healing

• G: Subsequent encounter for fracture with delayed healing

• S: Sequela

For other pathological fractures, the available episode of care designations include:

• A: Initial encounter for fracture

• D: Subsequent encounter for fracture with routine healing

• G: Subsequent encounter for fracture with delayed healing

• K: Subsequent encounter for fracture with nonunion

• P: Subsequent encounter for fracture with malunion

• S: Sequela

Acute traumatic versus old or chronic conditions
Acute traumatic and old or chronic conditions must be clearly differentiated in the documentation.

Acute traumatic conditions are reported with codes from Chapter 19 Injury, Poisoning and Certain Other Consequences of External Causes in ICD-10-CM, while old or chronic conditions are reported with codes from Chapter 13 Diseases of the Musculoskeletal System and Connective Tissue.

For example, an old bucket handle tear of the knee is reported with a code from subcategory M23.2- Derangement of meniscus due to old tear or injury; whereas an acute current bucket handle tear is reported with a code from subcategory S83.2- Tear of meniscus, current injury.

Intraoperative and post-procedural complications
Many codes for intraoperative and post-procedural complications and disorders of the musculoskeletal system are found at the end of Chapter 13 in category M96.

This category contains codes for conditions such as postlaminectomy syndrome, postradiation kyphosis and scoliosis, and pseudoarthrosis after surgical fusion or arthrodesis.

It also contains codes for intraoperative hemorrhage and hematoma, accidental puncture or laceration, and post-procedural hemorrhage or hematoma of musculoskeletal system structures, all of which require documentation of the procedure as a musculoskeletal procedure or a procedure on another body system.

Combination codes
While ICD-9-CM utilized combination codes for some conditions, the number of combination codes has been expanded in ICD-10-CM.

An example of a combination code that captures a disease process and a common symptom of that disease is found category M47 Spondylosis. Codes are now provided for spondylosis (disease process) with radiculopathy and with myelopathy (symptom).

Reclassification of conditions
Some conditions have been reclassified to new chapters or categories in ICD-10-CM.

In the case of musculoskeletal system and connective tissue diseases, there are now several code categories for gout, a condition that is classified in Chapter 3 Endocrine, Nutritional, and Metabolic Diseases in ICD-9-CM. Gout is classified in Chapter 13 in ICD-10-CM with categories for chronic gout (M1A.-) and gout (acute, gout attack/flare, gout NOS) (M10.-).

These two categories are further subdivided into idiopathic gout, lead-induced gout, drug-induced gout, gout due to renal impairment, and other secondary gout.

Summary
These are examples of just a few of the differences between documentation requirements in ICD-9-CM and ICD-10-CM.

Physicians and coders will need to review the components involved in ICD-10-CM code selection and current medical record documentation prior to ICD-10-CM implementation in order to identify any documentation deficiencies and implement a corrective action plan.

Editor's note:

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