CDI by Service –Musculoskeletal Diseases/Orthopedic Surgery #ICD10 #ICDRemediator #ICD10Matters #HealthIT

Clinical Documentation Improvement by Service –Musculoskeletal Diseases/Orthopedic Surgery

Written by  Laurie M. Johnson, MS, RHIA, CPC-H, FAHIMA | Monday, 03 November 2014 00:00



EDITOR’S NOTE: This is the third article is the continuation of a series of articles on clinical documentation improvement by clinical service.   



Musculoskeletal disease treatment and orthopedic surgery: Coding of these services will be challenging under ICD-10-CM/PCS. What are the necessary documentation changes? Let’s take a look at some examples.



Osteoarthritis: The documentation of osteoarthritis does not change significantly between the two classification systems. ICD-10-CM has the sub-classifications of secondary, primary, post-traumatic, and generalized, which is different from the “localized” and “generalized” classifications used in ICD-9-CM. The most obvious change between the two is that ICD-10-CM can identify laterality, which should impact claims editing. For example, X-rays performed on the right knee should have a diagnosis that identifies the right knee.



Complications of a Device: These can include mechanical issues and infections in both classification systems, but ICD-10-CM provides more specificity regarding the joint (laterality and anatomic site) with the complication. The complication type (loosening, pain, infection, prosthetic fracture, misalignment, etc.) should be clearly documented in the clinical information. Both classification systems have an instruction to add the joint replacement status code. For example, in ICD-9-CM, 996.44 represents the peri-prosthetic fracture around the prosthetic joint. If the knee joint is the problem area, then V43.65 would be an additional code. In ICD-10-CM, T84.842A represents the peri-prosthetic fracture around the right knee joint. In this case, the “use additional code to indicate the joint replacement status” is not needed. ICD-10-CM provides more information in one code regarding the laterality, the exact site, and the episode of care. In the previous example, while ICD-9-CM does give specific information regarding the type of complication, it never provides the laterality specificity.





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