Orthopaedic ICD-10 CM Training

ICD-10-CM will be valid for dates of service on or after October 1, 2015 – Outpatient dates of service of October 1, 2015 and beyond. – Inpatient hospital service claims, is effective for dates of discharge after September 30, 2015 ICD-10-CM Compliance Dates

Covered Entities – Everyone covered by the Health Insurance Portability Accountability Act (HIPPA) Non-Covered Entities – Worker’s Compensation – Auto Insurance – Non covered HIPAA entities are exempt but are encouraged to adapt the new code set Covered and Non-Covered Entities

21 Chapters Alpha-numeric codes; not case-sensitive – Codes begin with Alpha letter, A-Z, excluding U – Common errors I verses 1 O verses 0 “X” Placeholder 3 to 7 characters – Decimal following 3 rd character ICD-10 Code Structure

Placeholder “X” – Used for future expansion of a code – Fills in empty characters when a 6 th and/or 7 th character apply – The placeholder may be used in different scenarios but should never serve as the final character. Example: W19.XXXA Unspecified fall, Initial Encounter ICD-10 Code Structure

7 th Character – Provides specified information regarding the clinical visit – Is required for certain categories and must be reported in the seventh position – May be alpha or numeric – Has different meanings depending on the coding category ICD-10 Code Structure

Laterality – Some I CD-10-CM codes indicate laterality, specifying whether the condition occurs on the left, right or is bilateral. – If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side. – If the side is not identified in the medical record, assign the code for the unspecified side. OGCR section 1.B.13 ICD-10 Code Structure

“Other” Codes – Codes titled “other” or “other specified” are for use when the information in the medical record provides detail for which a specific code does not exist. “Unspecified” Codes – Codes titled “unspecified” are for use when the information in the medical record is insufficient to assign a more specific code. OGCR section 1.A.9.a.b ICD-10 Code Structure

Excludes Notes – Excludes1 A type 1 Excludes note is a pure excludes note It means “NOT CODED HERE” The code excluded should never be used at the same time When two conditions cannot occur togethe r – Excludes2 Represents “Not included here” The condition excluded is not part of the condition represented by the code It is acceptable to use both the code and the excluded code together, when appropriate OGCR section 1.A.12.a.b ICD-10 Structure

“Code First” and “Use Additional Code” – ICD-10 has a coding convention that requires the underlying condition be sequenced first followed by the manifestation. – These instructional notes indicate the proper sequencing order of the codes. OGCR section 1.A.13 The “-” indicates there are additional reporting options ICD-10 Code Structure

Most Common Diagnosis Codes

Pain of Joint Category M25.5 Excludes1Excludes2 Contracture of muscle without contracture of joint (M62.4-) Contracture of tendon (sheath) without contracture of joint (M62.4-) Dupuytren’s contracture (M72.0) acquired deformities of limbs (M20-M21)

Pain, Shoulder ICD-9 CodeICD-10 CodeDescription M25.511Pain, right shoulder M25.512Pain, left shoulder M25.519Pain, unspecified shoulder Pain, Elbow ICD-9 CodeICD-10 CodeDescription M25.521Pain, right elbow M25.522Pain, left elbow M25.529Pain, unspecified elbow Pain, Wrist ICD-9 CodeICD-10 CodeDescription M25.531Pain, right wrist M25.532Pain, left wrist M25.539Pain, unspecified wrist Pain, Hip ICD-9 CodeICD-10 CodeDescription M25.551Pain, right hip M25.552Pain, left hip M25.559Pain, unspecified hip Pain, Knee ICD-9 CodeICD-10 CodeDescription M25.561Pain, right knee M25.562Pain, left knee M25.569Pain, unspecified knee

Pain, Ankle and Foot ICD-9 CodeICD-10 Code Description M25.571Pain, right ankle and foot M25.572Pain, left ankle and foot M25.579Pain, unspecified ankle and foot Pain, Unspecified Joint M25.50Pain, unspecified joint Documentation Tips Site Laterality – Right – Left – Unspecified Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition.

Documentation Tips Bone versus joint – For certain conditions, the bone may be affected at the upper or lower end, (e.g., avascular necrosis of bone, M87, Osteoporosis, M80, M81). Though the portion of the bone affected may be at the joint, the site designation will be the bone, not the joint.

Osteoarthritis of knee ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes M17.9Osteoarthritis of knee, unspecified N/A osteoarthritis of spine (M47.-) There are more specific code choice selections below: M17.0Bilateral primary osteoarthritis of knee M17.10Unilateral primary osteoarthritis, unspecified knee M17.11Unilateral primary osteoarthritis, right knee M17.12Unilateral primary osteoarthritis, left knee M17.2Bilateral post-traumatic osteoarthritis of knee M17.30Unilateral post-traumatic osteoarthritis, unspecified knee M17.31Unilateral post-traumatic osteoarthritis, right knee M17.32Unilateral post-traumatic osteoarthritis, left knee M17.4Other bilateral secondary osteoarthritis of knee M17.5Other unilateral secondary osteoarthritis of knee

Identify – Site – Laterality – Type Primary Post-traumatic Other secondary Unspecified Documentation Tips

Osteoarthritis of hip ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes M16.9Osteoarthritis of hip, unspecified bilateral involvement of single joint (M16- M19) osteoarthritis of spine (M47.-) There are more specific code choice selections below: M16.0Bilateral primary osteoarthritis of hip M16.10Unilateral primary osteoarthritis, unspecified hip M16.11Unilateral primary osteoarthritis, right hip M16.12Unilateral primary osteoarthritis, left hip M16.2Bilateral osteoarthritis resulting from hip dysplasia M16.30Unilateral osteoarthritis resulting from hip dysplasia, unspecified hip M16.31Unilateral osteoarthritis resulting from hip dysplasia, right hip M16.32Unilateral osteoarthritis resulting from hip dysplasia, left hip M16.4Bilateral post-traumatic osteoarthritis of hip M16.50Unilateral post-traumatic osteoarthritis, unspecified hip M16.51Unilateral post-traumatic osteoarthritis, right hip M16.52Unilateral post-traumatic osteoarthritis, left hip M16.6Other bilateral secondary osteoarthritis of hip M16.7Other unilateral secondary osteoarthritis of hip

Identify: Laterality Bone versus joint For certain conditions, the bone may be affected at the upper or lower end, (e.g., avascular necrosis of bone, M87, Osteoporosis, M80, M81). Though the portion of the bone affected may be at the joint, the site designation will be the bone, not the joint. Documentation Tips

Cardiac murmur, unspecified ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes M75.110Incomplete rotator cuff tear or rupture of unspecified shoulder, not specified as traumatic Tear of rotator cuff, traumatic (S46.01-) Shoulder-hand syndrome (M89.0-) There are more specific code choice selections below: M75.111Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic M75.112Incomplete rotator cuff tear or rupture of left shoulder, not specified as traumatic

Note: Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition Identify: Laterality Documentation Tips

Unspecified fracture of forearm ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes S52.90xAUnspecified fracture of unspecified forearm Traumatic amputation of forearm (S58.-) Fracture of wrist and hand level (S62.-) There are more specific code choice selections below: S52.91x-Unspecified fracture of right forearm S52.92x-Unspecified fracture of left forearm The appropriate 7th character is to be added to all codes from category S52 A - initial encounter for closed fracture B - initial encounter for open fracture type I or II initial encounter for open fracture NOS C - initial encounter for open fracture type IIIA, IIIB, or IIIC D - subsequent encounter for closed fracture with routine healing E - subsequent encounter for open fracture type I or II with routine healing F - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing G - subsequent encounter for closed fracture with delayed healing H - subsequent encounter for open fracture type I or II with delayed healing J - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing K - subsequent encounter for closed fracture with nonunion M - subsequent encounter for open fracture type I or II with nonunion N - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion P - subsequent encounter for closed fracture with malunion Q - subsequent encounter for open fracture type I or II with malunion R - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion S - sequela

A fracture not indicated as open or closed should be coded to closed. A fracture not indicated whether displaced or not displaced should be coded to displaced. The open fracture designations are based on the Gustilo open fracture classification Identify: – Laterality Documentation Tips

Low back pain ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes M54.5Low back pain Loin pain Lumbago NOS psychogenic dorsalgia (F45.41) low back strain (S39.012) lumbago due to intervertebral disc displacement (M51.2-) lumbago with sciatica (M54.4-) N/A

Document site and laterality – Unspecified codes should be used only in rare circumstances With or without sciatica Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition. Low Back Pain Documentation Tips

Trochanteric bursitis ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes M70.60Trochanteric bursitis, unspecified hip Applicable to: Trochanteric tendinitis bursitis NOS (M71.9-) bursitis of shoulder (M75.5) enthesopathies (M76- M77) pressure ulcer (pressure area) (L89.-) M70.70Other bursitis of hip, unspecified hip M76.10Psoas tendinitis, unspecified hip M76.20Iliac crest spur, unspecified hip There are more specific code choice selections below: M70.60Trochanteric bursitis, unspecified hip M70.61Trochanteric bursitis, right hip M70.62Trochanteric bursitis, left hip

Identify: laterality Documentation Tips

Carpal tunnel syndrome, unspecified upper limb ICD-9 CodeICD-10 Code DescriptionExcludes1Excludes G56.00Carpal tunnel syndrome, unspecified upper limb current traumatic nerve disorder - see nerve injury by body region N/A There are more specific code choice selections below: G56.01Carpal tunnel syndrome, right upper limb G56.02Carpal tunnel syndrome, leftt upper limb

Identify: Laterality Documentation Tips

Unspecified intracapsular fracture of femur ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes S72.019AUnspecified intracapsular fracture of femur Applicable to: Subcapital fracture of femur traumatic amputation of hip and thigh (S78.-) fracture of lower leg and ankle (S82.-) fracture of foot (S92.-) periprosthetic fracture of prosthetic implant of hip (T84.040, T84.041) There are more specific code choice selections below: S Unspecified intracapsular fracture of right femur S Unspecified intracapsular fracture of left femur The appropriate 7th character is to be added to all codes from category S72 A - initial encounter for closed fracture B - initial encounter for open fracture type I or II initial encounter for open fracture NOS C - initial encounter for open fracture type IIIA, IIIB, or IIIC D - subsequent encounter for closed fracture with routine healing E - subsequent encounter for open fracture type I or II with routine healing F - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing G - subsequent encounter for closed fracture with delayed healing H - subsequent encounter for open fracture type I or II with delayed healing J - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing K - subsequent encounter for closed fracture with nonunion M - subsequent encounter for open fracture type I or II with nonunion N - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion P - subsequent encounter for closed fracture with malunion Q - subsequent encounter for open fracture type I or II with malunion R - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion S - sequela

A fracture not indicated as open or closed should be coded to closed The open fracture designations are based on the Gustilo open fracture classification Identify: – Laterality – Open or closed Documentation Tips

Pain in limb ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes M79.60-Pain in limb, unspecified psychogenic rheumatism (F45.8) soft tissue pain, psychogenic (F45.41) Pain in joint (M25.5-) There are more specific code choice selections below: 729.5M79.62-Pain in upper arm 729.5M79.63-Pain in forearm 729.5M79.64-Pain in hand and fingers 729.5M79.65-Pain in thigh 729.5M79.66-Pain in leg 729.5M79.67-Pain in foot and toes

Site Laterality Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition Documentation Tips

Sprain of unspecified rotator cuff capsule ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes S43.429ASprain of unspecified rotator cuff capsule, initial encounter rotator cuff syndrome (complete) (incomplete), not specified as traumatic (M75.1-) strain of muscle, fascia and tendon of shoulder and upper arm (S46.-) injury of tendon of rotator cuff (S46.0-) 840.4S43.429DSprain of unspecified rotator cuff capsule, subsequent encounter 840.4S43.429SSprain of unspecified rotator cuff capsule, sequela Code also any associated open wound There are more specific code choice selections below: S Sprain of right rotator cuff capsule S Sprain of left rotator cuff capsule S Sprain of unspecified rotator cuff capsule

Use secondary code(s) from Chapter 20, External causes of morbidity, to indicate cause of injury. Codes within the T section that include the external cause do not require an additional external cause code The chapter uses the S-section for coding different types of injuries related to single body regions and the T-section to cover injuries to unspecified body regions as well as poisoning and certain other consequences of external causes. Identify: – Laterality Documentation Tips

Secondary osteoarthritis, shoulder ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes M19.219Secondary osteoarthritis, unspecified shoulder Polyarthritis (M15.1-) arthrosis of spine (M47.-) Hallux rigidus (M20.2) osteoarthritis of spine (M47.-) There are more specific code choice selections below: M19.211Secondary osteoarthritis, right shoulder M19.212Secondary osteoarthritis, left shoulder

Identify: – Laterality – Primary, Secondary, Post-traumatic Documentation Tips

Displaced intertrochanteric fracture of femur ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes S Displaced intertrochanteric fracture of unspecified femur traumatic amputation of hip and thigh (S78.-) fracture of lower leg and ankle (S82.-) fracture of foot (S92.-) periprosthetic fracture of prosthetic implant of hip (T84.040, T84.041) There are more specific code choice selections below: S Displaced intertrochanteric fracture of right femur S Displaced intertrochanteric fracture of left femur The appropriate 7th character is to be added to all codes from category S72 A - initial encounter for closed fracture B - initial encounter for open fracture type I or II initial encounter for open fracture NOS C - initial encounter for open fracture type IIIA, IIIB, or IIIC D - subsequent encounter for closed fracture with routine healing E - subsequent encounter for open fracture type I or II with routine healing F - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing G - subsequent encounter for closed fracture with delayed healing H - subsequent encounter for open fracture type I or II with delayed healing J - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing K - subsequent encounter for closed fracture with nonunion M - subsequent encounter for open fracture type I or II with nonunion N - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion P - subsequent encounter for closed fracture with malunion Q - subsequent encounter for open fracture type I or II with malunion R - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion S - sequela

A fracture not indicated as open or closed should be coded to closed The open fracture designations are based on the Gustilo open fracture classification Identify: – Laterality Documentation Tips

Other specified postprocedural states ICD-9 CodeICD-10 CodeDescriptionExcludes1Excludes2 V45.89Z98.89Other specified postprocedural states Applicable To: Personal history of surgery, not elsewhere classified N/A Code also any follow-up examination (Z08-Z09)

Note: Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is performed. Categories Z00- Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y89 are recorded as 'diagnoses' or 'problems'. This can arise in two main ways: (a) When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination (immunization), or to discuss a problem which is in itself not a disease or injury. (b) When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury. Documentation Tips

On October 01, 2015 we will monitor claims for date of service rules Outpatient claims cannot have crossover dates Outpatient claims will be coded according to date of service Inpatient facility claims will be coded per date of discharge We will monitor claims to resolve any unanticipated problems with the submission process Monitor Claims

We will monitor for claim denials We will monitor editing trends for ICD-10 Coding guidelines We will provide feedback to the physicians regarding supporting documentation requirements We will monitor WC or Liability carriers for published rules on use of ICD-9 or ICD-10 code sets Claim Denial and Management

Client will need to update – Templates – Order Sets – Superbills – Favorites Future Orders – Remove ICD-9 code add ICD-10 code Client Responsibilities

All Conditions treated or assessed must be documented in the medical record. In addition to the documentation tips reviewed, below are more areas to document that will ensure proper ICD-10-CM code selection. Site specificity Document notation of qualifiers – Exacerbation – Manifestations – Relapse – Status – Stages Indicate acute or chronic Indicate underlying or external cause factors – Medication – Smoke – Accidents – Mechanical failure Laterality – Bilateral – Right – Left Documentation – Start Now

Episode of Care for injuries, poisoning, external causes and other conditions – Initial Encounter Use while the patient is receiving active treatment of the condition – Active treatment includes surgical treatment, an emergency encounter, and evaluation and treatment by a new physician – Subsequent Encounter Used on encounter after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. – Medication adjustments, aftercare, device adjustments, cast change – Sequela Used for complications or conditions that arise as a direct result of a condition, late effect Documentation – Start Now

Combination codes that capture – Etiology and manifestation – Related conditions – Disease, injury or other medical condition and complications – Disease or other medical conditions and common signs or symptoms Add ICD-10 Codes to patient Problem List Documentation – Start Now

Centers for Disease Control and Prevention (ICD-10-CM)