ICD-10: Clinical Concepts for Orthopedics

ICD-10

Clinical Concepts for Orthopedics

ICD-10 Clinical Concepts Series

Common Codes Clinical Documentation Tips Clinical Scenarios

ICD-10 Common Codes for Orthopedics is a feature of Road to 10, a CMS online tool built with physician input.

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ICD10

ICD-10 Compliance Date: October 1, 2015

Official CMS Industry Resources for the ICD-10 Transition ICD10

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Table Of Contents

Common Codes

? Cervical Spine Disorders and Displacement

? Neck and Back Pain ? Osteoarthritis of

the Hip ? Osteoarthritis of the Knee ? Radiculopathy (Primary) ? Rheumatoid Arthritis

Clinical Documentation Tips

? Fractures ? Arthritis ? Injuries

Clinical Scenarios

? Scenario 1: Fracture Follow-Up Visit

? Scenario 2: Shoulder ROM Office Visit

? Scenario 3: Tear of Medial Meniscus With Anterior Cruciate Ligament Injury

? Selected Shoulder Conditions

? Spinal Stenosis of the Lumbar Region

? Selected Sprains ? Rotator Cuff, Cruciate Ligament, and Ankle

? Thoracic, Thoracolumbar, and Lumbosacral Intervertebral Disc Disorders

? Scenario: Cervical Disc Disease

? Scenario: Struck by Car ? Scenario: Fracture

Common Codes

ICD-10 Compliance Date: October 1, 2015

Cervical Spine Disorders and Displacement (ICD-9-CM 722.0, 722.4, 722.71, 722.91, 723.4)

M50.00* M50.01 M50.02 M50.03 M50.10* M50.11 M50.12 M50.13 M50.20* M50.21 M50.22 M50.23 M50.30* M50.31 M50.32 M50.33 M50.80* M50.81 M50.82 M50.83 M50.90* M50.91 M50.92 M50.93

Cervical disc disorder with myelopathy, unspecified cervical region Cervical disc disorder with myelopathy, occipito-atlanto-axial 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, occipito-atlanto-axial 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, occipito-atlanto-axial region Other cervical disc displacement, mid-cervical region Other cervical disc displacement, cervicothoracic region Other cervical disc degeneration, unspecified cervical region Other cervical disc degeneration, occipito-atlanto-axial region Other cervical disc degeneration, mid-cervical region Other cervical disc degeneration, cervicothoracic region Other cervical disc disorders, unspecified cervical region Other cervical disc disorders, occipito-atlanto-axial region Other cervical disc disorders, mid-cervical region Other cervical disc disorders, cervicothoracic region Cervical disc disorder, unspecified, unspecified cervical region Cervical disc disorder, unspecified, occipito-atlanto-axial region Cervical disc disorder, unspecified, mid-cervical region Cervical disc disorder, unspecified, cervicothoracic region

*Codes with a greater degree of specificity should be considered first.

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Neck and Back Pain (ICD-9-CM 723.1, 724.1, 724.2, 724.3, 724.5)

M54.2 M54.30* M54.31 M54.32 M54.40* M54.41 M54.42 M54.5 M54.6 M54.89 M54.9*

Cervicalgia Sciatica, unspecified side Sciatica, right side Sciatica, left side Lumbago with sciatica, unspecified side Lumbago with sciatica, right side Lumbago with sciatica, left side Low back pain Pain in thoracic spine Other dorsalgia Dorsalgia, unspecified

*Codes with a greater degree of specificity should be considered first.

Osteoarthritis of the Hip (ICD-9-CM 715.15, 715.25, 715.35, 715.95)

M16.0 M16.10* M16.11 M16.12 M16.2 M16.30* M16.31 M16.32 M16.4 M16.50* M16.51 M16.52 M16.6 M16.7 M16.9*

Bilateral primary osteoarthritis of hip Unilateral primary osteoarthritis, unspecified hip Unilateral primary osteoarthritis, right hip Unilateral primary osteoarthritis, left hip Bilateral osteoarthritis resulting from hip dysplasia Unilateral osteoarthritis resulting from hip dysplasia, unspecified hip Unilateral osteoarthritis resulting from hip dysplasia, right hip Unilateral osteoarthritis resulting from hip dysplasia, left hip Bilateral post-traumatic osteoarthritis of hip Unilateral post-traumatic osteoarthritis, unspecified hip Unilateral post-traumatic osteoarthritis, right hip Unilateral post-traumatic osteoarthritis, left hip Other bilateral secondary osteoarthritis of hip Other unilateral secondary osteoarthritis of hip Osteoarthritis of hip, unspecified

*Codes with a greater degree of specificity should be considered first.

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Osteoarthritis of the Knee (ICD-9-CM 715.16, 715.26, 715.36, 715.96)

M17.0 M17.10* M17.11 M17.12 M17.2 M17.30* M17.31 M17.32 M17.4 M17.5 M17.9*

Bilateral primary osteoarthritis of knee Unilateral primary osteoarthritis, unspecified knee Unilateral primary osteoarthritis, right knee Unilateral primary osteoarthritis, left knee Bilateral post-traumatic osteoarthritis of knee Unilateral post-traumatic osteoarthritis, unspecified knee Unilateral post-traumatic osteoarthritis, right knee Unilateral post-traumatic osteoarthritis, left knee Other bilateral secondary osteoarthritis of knee Other unilateral secondary osteoarthritis of knee Osteoarthritis of knee, unspecified

*Codes with a greater degree of specificity should be considered first.

Radiculopathy (Primary) (ICD-9-CM 723.4, 724.3, 724.4, 729.2)

M54.10* M54.11 M54.12 M54.13 M54.14 M54.15 M54.16 M54.17 M54.18 M54.30* M54.31 M54.32

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

*Codes with a greater degree of specificity should be considered first.

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Rheumatoid Arthritis (ICD-9-CM 714.0, 714.2) Excludes Combination Codes that Include Neuropathy, Bursitis and Nodule Codes, and the Codes that Indicate "Unspecified Site".

M05.611 M05.612 M05.619* M05.621 M05.622 M05.629* M05.631 M05.632 M05.639* M05.641 M05.642 M05.649* M05.651 M05.652 M05.659* M05.661

Rheumatoid arthritis of right shoulder with involvement of other organs and systems Rheumatoid arthritis of left shoulder with involvement of other organs and systems Rheumatoid arthritis of unspecified shoulder with involvement of other organs and systems Rheumatoid arthritis of right elbow with involvement of other organs and systems Rheumatoid arthritis of left elbow with involvement of other organs and systems Rheumatoid arthritis of unspecified elbow with involvement of other organs and systems Rheumatoid arthritis of right wrist with involvement of other organs and systems Rheumatoid arthritis of left wrist with involvement of other organs and systems Rheumatoid arthritis of unspecified wrist with involvement of other organs and systems Rheumatoid arthritis of right hand with involvement of other organs and systems Rheumatoid arthritis of left hand with involvement of other organs and systems Rheumatoid arthritis of unspecified hand with involvement of other organs and systems Rheumatoid arthritis of right hip with involvement of other organs and systems Rheumatoid arthritis of left hip with involvement of other organs and systems Rheumatoid arthritis of unspecified hip with involvement of other organs and systems Rheumatoid arthritis of right knee with involvement of other organs and systems

*Codes with a greater degree of specificity should be considered first.

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Rheumatoid Arthritis (ICD-9-CM 714.0, 714.2) Excludes Combination Codes that Include Neuropathy, Bursitis and Nodule Codes, and the Codes that Indicate "Unspecified Site". (continued)

M05.662 M05.669* M05.671 M05.672 M05.679* M05.69 M05.711 M05.712 M05.719* M05.721 M05.722 M05.729* M05.731 M05.732 M05.739* M05.741

Rheumatoid arthritis of left knee with involvement of other organs and systems Rheumatoid arthritis of unspecified knee with involvement of other organs and systems Rheumatoid arthritis of right ankle and foot with involvement of other organs and systems Rheumatoid arthritis of left ankle and foot with involvement of other organs and systems Rheumatoid arthritis of unspecified ankle and foot with involvement of other organs and systems Rheumatoid arthritis of multiple sites with involvement of other organs and systems Rheumatoid arthritis with rheumatoid factor of right shoulder without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of unspecified shoulder without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of right elbow without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of left elbow without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of unspecified elbow without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of left wrist without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of unspecified wrist without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of right hand without organ or systems involvement

*Codes with a greater degree of specificity should be considered first.

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Rheumatoid Arthritis (ICD-9-CM 714.0, 714.2) Excludes Combination Codes that Include Neuropathy, Bursitis and Nodule Codes, and the Codes that Indicate "Unspecified Site". (continued)

M05.742

M05.749*

M05.751

M05.752

M05.759*

M05.761

M05.762

M05.769*

M05.771

M05.772

M05.779*

M05.79

M05.811 M05.812 M05.819* M05.821 M05.822 M05.829* M05.831 M05.832

Rheumatoid arthritis with rheumatoid factor of left hand without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of unspecified hand without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of right hip without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of left hip without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of unspecified hip without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of unspecified knee without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot without organ or systems involvement Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement Other rheumatoid arthritis with rheumatoid factor of right shoulder Other rheumatoid arthritis with rheumatoid factor of left shoulder Other rheumatoid arthritis with rheumatoid factor of unspecified shoulder Other rheumatoid arthritis with rheumatoid factor of right elbow Other rheumatoid arthritis with rheumatoid factor of left elbow Other rheumatoid arthritis with rheumatoid factor of unspecified elbow Other rheumatoid arthritis with rheumatoid factor of right wrist Other rheumatoid arthritis with rheumatoid factor of left wrist

*Codes with a greater degree of specificity should be considered first.

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