Chapter 15
DISEASES OF THE MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE
Introduction
Codes for diseases of the musculoskeletal system and connective tissue are found in
Chapter 15 in ICD-10-CM. Like many of the other chapters, the documentation needed to code conditions of the musculoskeletal system accurately require specificity and detail. For example, conditions affecting the cervical spine now require identification of the level as occipito-atlanto-axial or high cervical region, mid-cervical region identified by level C3-4, C4-5, C5-6 or cervicothoracic region. Laterality is also included for most musculoskeletal and connective tissue conditions affecting the extremities. For some conditions only right and left is provided, but for other conditions that frequently affect both sides, codes for bilateral are listed. Although not a new documentation requirement, physicians will need to clearly document whether the condition being treated is an acute traumatic condition, in which case it is reported with an injury code from
Chapter 19, or an old or chronic condition, in which case it is reported with a code from
Chapter 15. Pathologic fractures are reported based upon the causation such as due to neoplastic or other disease, location as well as episode of care. While episode of care is often clearly evident from the nature of the visit, (i.e. a follow-up visit to evaluate healing of a pathological fracture) current documentation should be reviewed to ensure that the initial episode of care is clearly differentiated from subsequent visits for routine healing, delayed healing, malunion, or nonunion of these fractures. If the condition is a sequela of a pathological fracture, that information should also be clearly noted in the medical record as this is also captured with the code for the pathological fracture. Additionally, each visit must be specific in defining the fracture. No longer can the providers merely state the patient is being seen for follow-up of a tibia fracture.
A good way to begin an analysis of documentation and coding requirements for each chapter is to be familiar with the chapter sections and ICD-10-CM chapter blocks. A table containing this information is provided below.
ICD-10-CM Blocks |
M00-M02 |
Infectious Arthropathies |
M05-M14 |
Inflammatory Polyarthropathies |
M15-M19 |
Osteoarthritis |
M20-M25 |
Other Joint Disorders |
M26-M27 |
Dentofacial Anomalies [Including Malocclusion] and Other Disorders of Jaw |
M30-M36 |
Systemic Connective Tissue Disorders |
M40-M43 |
Deforming Dorsopathies |
M45-M49 |
Spondylopathies |
M50-M54 |
Other Dorsopathies |
M60-M63 |
Disorders of Muscles |
M65-M67 |
Disorders of Synovium and Tendon |
M70-M79 |
Other Soft Tissue Disorders |
M80-M85 |
Disorders of Bone Density and Structure |
M86-M90 |
Other Osteopathies |
M91-M94 |
Chondropathies |
M95 |
Other Disorders of the Musculoskeletal System and Connective Tissue |
M96 |
Intraoperative and Postprocedural Complications and Disorders of Musculoskeletal System, Not Elsewhere Classified |
M99 |
Biomechanical Lesions, Not Elsewhere Classified |
The categories of codes for the various diseases of the musculoskeletal system and connective tissues have expanded from previous systems to allow for more specific classification. For example, arthropathies and related disorders are classified based upon causation such as infection, inflammatory diseases or wear and tear arthritis as well as other disorders of the joint.
Coding Note(s)
There is single chapter level coding instruction in ICD-10-CM, which instructs the coder to use an external cause code, if applicable, to identify the cause of the musculoskeletal condition. The external cause code is sequenced after the code for the musculoskeletal condition.
Exclusions
There are only Excludes2 chapter level exclusions notes for
Chapter 13.
Excludes1 |
Excludes2 |
None |
Arthropathic psoriasis (L40.5-)
Certain conditions originating in the perinatal period (P04-P96)
Certain infectious and parasitic diseases (A00-B99)
Compartment syndrome (traumatic) (T79.A-)
Complications of pregnancy, childbirth, and the puerperium (O00-O9A)
Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)
Endocrine, nutritional and metabolic diseases (E00-E88)
Injury, poisoning and certain other consequences of external causes (S00-T88)
Neoplasms (C00-D49)
Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94) |
Chapter Guidelines
Chapter specific guidelines are provided for musculoskeletal system and connective tissue coding. In ICD-10-CM, guidelines are listed for pathological fractures as well as the following:
•Site and laterality
•Acute traumatic versus chronic or recurrent musculoskeletal conditions
•Coding of pathologic fractures
•Osteoporosis
Site and Laterality
Most codes in
Chapter 13 have site and laterality designations.
Site
•Site represents either the bone, joint, or the muscle involved
•For some conditions where more than one bone, joint, or muscle is usually involved, such as osteoarthritis, there is a “multiple sites” code available
•For categories where no multiple site code is provided and more than one bone, joint, or muscle is involved, multiple codes should be used to indicate the different sites involved
•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
Laterality
•Most conditions involving the extremities require documentation of right or left in addition to the specific site
•If laterality is not documented, there are codes for unspecified side; however, unspecified codes particularly those defining laterality should be used only in rare circumstances.
Acute Traumatic Versus Chronic or Recurrent Musculoskeletal Conditions
Many musculoskeletal conditions are a result of a previous injury or trauma to a site, or are recurrent conditions. Musculoskeletal conditions are classified either in
Chapter 13 Diseases of the Musculoskeletal System and Connective tissue or in
Chapter 19 Injury, Poisoning, and Certain Other Consequences of External Causes as follows:
•Healed injury – Bone, joint, or muscle conditions that are a result of a healed injury are usually found in
Chapter 13
•Recurrent condition – Recurrent bone, joint, or muscle conditions are usually found in
Chapter 13
•Chronic or other recurrent conditions – Conditions are generally reported with a code from
Chapter 13
•Current acute injury – Current, acute injuries are coded to the appropriate injury code in
Chapter 19
If it is difficult to determine from the available documentation whether the condition should be reported with a code from
Chapter 13 or
Chapter 19, the provider should be queried.
Coding of Pathologic Fractures
ICD-10-CM contains chapter guidelines for reporting pathologic fractures. These guidelines are primarily defining the use of the 7th character extension to define the episode of care. It is important that these guidelines be understood before coding for pathologic and stress fractures. Guidelines for use of the 7th character extension for coding pathologic fractures in ICD-10-CM are as follows:
•Initial encounter for fracture – The 7th character ‘A’ for initial episode of care is used for as long as the patient is receiving active treatment for the pathologic fracture. Examples of active treatment are:
–Surgical treatment
–Emergency department encounter
–Evaluation and continuing treatment by the same or different physician
•Subsequent encounter for fracture with routine healing – The 7th character ‘D’ is used for encounters after the patient has completed active treatment for the fracture and is receiving routine care for the fracture during the healing or recovery phase.
•Subsequent encounter for fracture with delayed healing – The 7th character ‘G’ for subsequent encounter for fracture with delayed healing is reported when the physician has documented that healing is delayed or is not occurring as rapidly as normally expected.
•Subsequent encounter for fracture with nonunion – The 7th character ‘K’ is reported when the physician has documented that there is nonunion of the fracture or that the fracture has failed to heal. This is a serious fracture complication that requires additional intervention and treatment by the physician.
•Subsequent encounter for fracture with malunion – The 7th character ‘P’ is reported when the fracture has healed in an abnormal or nonanatomic position. This is a serious fracture complication that requires additional intervention and treatment by the physician.
•Sequela – The 7th character ‘S’ is reported for complications or conditions that arise as a direct result of the pathological fracture, such as a leg length discrepancy following pathological fracture of the femur. The specific type of sequela is sequenced first followed by the pathological fracture code.
Care for complications of surgical treatment for pathological fracture repairs during the healing or recovery phase should be coded with the appropriate complication codes. See section I.C.19 of the Official Guidelines for information on coding of traumatic fractures.
Osteoporosis
Osteoporosis is a systemic condition, meaning that all bones of the musculoskeletal system are affected. Therefore, site is not a component of the codes under category M81 Osteoporosis without current pathological fracture. The site codes under M80 Osteoporosis with current pathological fracture identify the site of the fracture not the osteoporosis. Additional guidelines for osteoporosis are as follows:
•Osteoporosis without pathological fracture
–Category M81 Osteoporosis without current pathological fracture is for use for patients with osteoporosis who do not currently have a pathological fracture due to the osteoporosis, even if they had a fracture in the past
–For a patient with a history of osteoporosis fractures, status code Z87.31, Personal history of osteoporosis fracture should follow the code from M81
•Osteoporosis with current pathological fracture
–Category M80 Osteoporosis with current pathological fracture is for patients who have a current pathologic fracture at the time of an encounter
–The codes under M80 identify the site of the fracture
–A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone
General Documentation Requirements
When documenting diseases of the musculoskeletal system and connective tissue there are a number of general documentation requirements of which providers should be aware. The introduction and guidelines in the previous sections of this chapter identify some of the documentation requirements related to musculoskeletal and connective tissue diseases including more specific site designations and laterality. Documentation of episode of care is required for pathologic and stress fractures. The documentation must also clearly differentiate conditions that are acute traumatic conditions and those that are chronic or recurrent. Understanding documentation requirements for intraoperative and postprocedural complications will require a careful review of category M96 to ensure that the complication is described in sufficient detail to assign the most specific complication code. There are also combination codes that capture two or more related conditions, etiology and manifestations of certain conditions, or a disease process and common symptoms of the disease. Familiarity with the 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. A few examples of each of these general coding and documentation requirements are provided here. For those familiar with the former diagnosis system, ICD-10-CM has reclassified some conditions moving them into a different section. Such is the case of gout which was previously classified in
Chapter 3 Endocrine, Nutritional, and Metabolic Diseases in ICD-9-CM but is now classified in
Chapter 13 Diseases of the Musculoskeletal System and Connective Tissue.
Site
Site specificity is an important component of musculoskeletal system and connective tissue codes. Dorsopathies, which are conditions affecting the spine and intervertebral joints, provide a good example of site specificity. Codes for ankylosis (fusion) of the spine (M43.2-) are specific to the spine level and the ankylosis should be specified as affecting the occipito-atlanto-axial region, cervical region, cervicothoracic region, thoracic region, thoracolumbar region, lumbar region, lumbosacral region, or sacral and sacrococcygeal region.
Laterality
Laterality is required for the vast majority of musculoskeletal and connective tissue diseases and other conditions affecting the extremities. For example, trigger finger requires documentation of the specific finger (thumb, index finger, middle finger, ring finger, or little finger) and laterality (right, left). While there are also unspecified codes for unspecified finger and unspecified laterality, these codes should rarely be used because the affected finger and laterality should always be documented. Omission of this level of detail indicates to the health plan that the patient was not examined. An example of a condition where codes are available for bilateral conditions as well as for right and left is osteoarthritis of the hip (M16), knee (M17), and first carpometacarpal joints (M18). So, if a patient has primary arthritis of the knee, the physician must document both the condition and the site-specific location: right, left or bilateral. For osteoarthritis affecting other joints, there are codes for right and left but not for bilateral. If both joints of one of these sites is affected, two codes—one for the right and one for the left, are assigned.
Episode of Care
Documentation of episode of care is required for pathologic and stress 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 disease (M84.6-). For these conditions, a 7th character extension is required identifying the episode of care as:
AInitial encounter for fracture
DSubsequent encounter for fracture with routine healing
GSubsequent encounter for fracture with delayed healing
KSubsequent encounter for fracture with nonunion
PSubsequent encounter for fracture with malunion
SSequela
The physician must clearly document the episode of care and for subsequent encounters must identify whether the healing is routine or delayed or whether it is complicated by nonunion or malunion. Documentation of the fracture type (stress, pathologic and cause), location (femur, humerus, etc.) and laterality must be documented for each encounter where the patient is being seen for the condition. Codes cannot be assigned based upon prior detailed documentation. Any conditions resulting from a previous pathological fracture must also be clearly documented as sequela so the appropriate pathological fracture sequela code can be assigned in addition to the condition being treated.
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, while old or chronic conditions are reported with codes from
Chapter 13. 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 Postprocedural Complications NEC
Many codes for intraoperative and postprocedural 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 postprocedural hemorrhage or hematoma of musculoskeletal system structures, which all require documentation of the procedure as a musculoskeletal procedure or a procedure on another body system.
Combination Codes
Combination codes may capture two or more related conditions, etiology and manifestations of certain conditions, or a disease process and common symptoms of the disease. Combination codes that capture two related conditions can be found in category M16 Osteoarthritis of the hip which defines the condition of osteoarthritis resulting from dysplasia (M16.2, M16.3-). An example of a combination code that captures a disease process and a common symptom of that disease is found in category M47 Spondylosis. Here codes are provided for spondylosis (disease process) with radiculopathy (symptom).
Code-Specific Documentation Requirements
In this section, ICD-10-CM code categories, subcategories, and subclassifications for some of the more frequently reported diseases of the musculoskeletal system and connective tissue are reviewed along with specific documentation requirements identified. The focus is on conditions with more specific clinical documentation requirements. Although not all codes with significant documentation requirements are discussed, this section will provide a representative sample of the type of additional documentation needed for diseases of the musculoskeletal system and connective tissue. The section is organized alphabetically by the ICD10-CM code category, subcategory, or subclassification depending on whether the documentation affects only a single code or an entire subcategory or category.
Contracture Tendon Sheath
A muscle contracture is a shortening of the muscle and/or tendon sheath which prevents normal movement and flexibility. Causes can include: prolonged immobilization, scarring (trauma, burns), paralysis (stroke, spinal cord injuries), ischemia (e.g., Volkmann’s contracture), cerebral palsy, and degenerative diseases affecting the muscles (e.g., muscular dystrophy).
A muscle spasm is a sudden, involuntary contraction of a single muscle or a muscle group. This condition is usually benign and self-limiting. The contraction of the muscle is temporary. Causes include abnormal or malfunctioning nerve signals, muscle fatigue (overuse, exertion), dehydration, electrolyte imbalance, decreased blood supply, and certain medications.
In ICD-10-CM, tendon and muscle contractures and muscle spasms are found under the section of soft tissue disorders. Subcategory M62.4 Contracture of muscle contains the alternate term contracture of tendon sheath, so a code from this subcategory is reported for either diagnosis. Codes in this subcategory are specific to site and documentation of laterality is also required. Muscle spasm is found under subcategory M62.83 and is further subdivided by muscle spasm of the back calf and other. Documentation requirements and clinical documentation for muscle or tendon contracture follows.
Coding and Documentation Requirements
Identify the site of the muscle or tendon contracture:
•Upper extremity
–Shoulder
–Upper arm
–Forearm
–Hand
•Lower extremity
–Thigh
–Lower leg
–Ankle/Foot
•Other site
•Multiple sites
•Unspecified site
For muscle/tendon contracture of extremity, identify laterality:
•Right
•Left
•Unspecified
ICD-10-CM Code/Documentation |
M62.40 |
Contracture of muscle unspecified site |
M62.411 |
Contracture of muscle, right shoulder |
M62.412 |
Contracture of muscle, left shoulder |
M62.419 |
Contracture of muscle, unspecified shoulder |
M62.421 |
Contracture of muscle, right upper arm |
M62.422 |
Contracture of muscle, left upper arm |
M62.429 |
Contracture of muscle, unspecified upper arm |
M62.431 |
Contracture of muscle, right forearm |
M62.432 |
Contracture of muscle, left forearm |
M62.439 |
Contracture of muscle, unspecified forearm |
M62.441 |
Contracture of muscle, right hand |
M62.442 |
Contracture of muscle, left hand |
M62.449 |
Contracture of muscle, unspecified hand |
M62.451 |
Contracture of muscle, right thigh |
M62.452 |
Contracture of muscle, left thigh |
M62.459 |
Contracture of muscle, unspecified thigh |
M62.461 |
Contracture of muscle, right lower leg |
M62.462 |
Contracture of muscle, left lower leg |
M62.469 |
Contracture of muscle, unspecified lower leg |
M62.471 |
Contracture of muscle, right ankle and foot |
M62.472 |
Contracture of muscle, left ankle and foot |
M62.479 |
Contracture of muscle, unspecified ankle and foot |
M62.48 |
Contracture of muscle, other site |
M62.49 |
Contracture of muscle, multiple sites |
Documentation and Coding Example
Fourteen-year-old Black male presents to Orthopedic Clinic with an interesting deformity to his right wrist. He is right hand dominant. Patient and mother give a history of a skateboard accident 10 months ago where he slammed into a metal pole causing a soft tissue injury to his right forearm. He developed an infected hematoma that was incised and drained and ultimately healed. ROM to elbow is intact. He is able to supinate and pronate fully. There is a moderate amount of ulnar deviation in the right wrist, causing focal disability. He has difficulty performing a pincher grasp, holding utensils and is unable to hold a small half-filled water bottle for more than a minute. X-rays of elbow, forearm, wrist unremarkable.
Impression: Contracture of right extensor carpi ulnaris tendon causing deformity and functional disability of the wrist and hand due to old soft tissue injury.
Plan: Occupational Therapy evaluation and authorization for 12 visits if approved by patient’s insurance company. RTC in one month.
Diagnosis Code(s)
M62.431 |
Contracture of muscle, right forearm |
S56.501S |
Unspecified injury of other extensor muscle, fascia and tendon at forearm level, sequela |
V00.132S |
Skateboarder colliding with stationary object, sequela |
Coding Note(s)
The extensor carpi ulnaris muscle is a muscle in the forearm, so the code for contracture of the right forearm muscle is reported. Contracture of tendon is reported with the same code as contracture of muscle. Based upon the documentation, the tendon/muscle contracture is a sequela of a soft tissue injury so an injury code with 7th character ‘S’ should also be reported. Coding of sequela will be covered in
Chapter 19 of this book. The external cause of the sequela (late effect) is specific to a skateboarder colliding with a stationary object.
Gouty Arthropathy
Gout is an arthritis-like condition caused by an accumulation of uric acid in the blood which leads to inflammation of the joints. Acute gout typically affects one joint. Chronic gout is characterized by repeated episodes of pain and inflammation in one or more joints. Following repeated episodes of gout, some individuals develop chronic tophaceous gout. This condition is characterized by solid deposits of monosodium urate (MSU) crystals, called tophi in the joints, cartilage, bones, and other areas of the body. In some cases, tophi break through the skin and appear as white or yellowish-white, chalky nodules on the skin.
Even though gout is often considered a metabolic disorder in its origins, ICD-10-CM classifies gout as a disease of the musculoskeletal system and connective tissue within two categories—M10 Gout and M1A Chronic gout. Gout may be due to toxic effects of lead or other drugs, renal impairment, other medical conditions, or an unknown cause (idiopathic). Category M10 includes gout due to any cause specified as acute gout, gout attack, gout flare, and other gout not specified as chronic. Subcategories identify the specific cause of the gout as idiopathic, lead-induced, drug-induced, due to renal impairment, due to other causes, or unspecified. Category M1A includes gout due to any cause specified as chronic.
Coding and Documentation Requirements
Identify type of gout:
•Chronic
•Other/unspecified, which includes:
–Acute gout
–Gout attack
–Gout flare
–Gout not otherwise specified
–Podagra
Identify cause:
•Drug-induced
•Idiopathic
•Lead-induced
•Renal impairment
•Other secondary gout
•Unspecified
Identify site:
•Lower extremity
–Ankle/foot
–Hip
–Knee
•Upper extremity
–Elbow
–Hand
–Shoulder
–Wrist
•Vertebrae
•Multiple sites
•Unspecified site
Identify laterality for extremities:
•Right
•Left
•Unspecified
For chronic gout, use a 7th character to identify any tophus:
•With tophus (1)
•Without tophus (0)
ICD-10-CM Code/Documentation |
M10.00 |
Idiopathic gout, unspecified site |
M10.011 |
Idiopathic gout, right shoulder |
M10.012 |
Idiopathic gout, left shoulder |
M10.019 |
Idiopathic gout, unspecified shoulder |
M10.021 |
Idiopathic gout, right elbow |
M10.022 |
Idiopathic gout, left elbow |
M10.029 |
Idiopathic gout, unspecified elbow |
M10.031 |
Idiopathic gout, right wrist |
M10.032 |
Idiopathic gout, left wrist |
M10.039 |
Idiopathic gout, unspecified wrist |
M10.041 |
Idiopathic gout, right hand |
M10.042 |
Idiopathic gout, left hand |
M10.049 |
Idiopathic gout, unspecified hand |
M10.051 |
Idiopathic gout, right hip |
M10.052 |
Idiopathic gout, left hip |
M10.059 |
Idiopathic gout, unspecified hip |
M10.061 |
Idiopathic gout, right knee |
M10.062 |
Idiopathic gout, left knee |
M10.069 |
Idiopathic gout, unspecified knee |
M10.071 |
Idiopathic gout, right ankle and foot |
M10.072 |
Idiopathic gout, left ankle and foot |
M10.079 |
Idiopathic gout, unspecified ankle and foot |
M10.08 |
Idiopathic gout, vertebrae |
M10.09 |
Idiopathic gout, multiple sites |
Documentation and Coding Example
Fifty-two-year-old Caucasian male presents to PMD with complaints of gout flare. PMH is significant for hypertension, seasonal allergies, and gout. Current medications include Lisinopril, Allopurinol, ASA, Enzyme CoQ10, Loratidine, and Nasonex spray. His only complaint is a swollen great toe which he attributes to a gout flare.
Temperature 97.4, HR 84, RR 14, BP 140/78, Wt. 189. On examination, this is a well-groomed, well-nourished male who looks his stated age. Skin is tan and he has a few scattered seborrheic keratoses lesions present on face and back. He is reminded to use sunscreen and a hat when outdoors. Peripheral pulses full. Right leg is unremarkable. Left knee and ankle normal. Left great toe is red, swollen, and tender to touch. He is advised to take OTC ibuprofen or naproxen for his toe pain and to avoid alcohol, limit meat for a few weeks. He will return in 1 week for a recheck of his great toe.
Diagnosis: Primary gout with gout flare left great toe.
Diagnosis Code(s)
M10.072 |
Idiopathic gout, left ankle and foot |
Coding Note(s)
The patient has a history of gout and is being seen for a gout flare. The inclusion terms under M10 Gout includes gout flare. Reporting a code for chronic gout requires specific documentation of the gout as a chronic condition. In addition, if the patient has chronic gout and a gout flare, report only the code for the gout flare. There is an Excludes1 note indicating that chronic gout (category M1A) is never reported with acute gout (category M10).
Intervertebral Disc Disorders
Intervertebral disc disorders include conditions such as displacement, Schmorl’s nodes, degenerative disc disease, intervertebral disc disorders, postlaminectomy syndrome, and other and unspecified disc disorders. Like spondylosis, several combination codes exist to define the disc disorder as well as associated symptoms of radiculopathy or myelopathy. Displacement of an intervertebral disc may also be referred to as ruptured or herniated intervertebral disc or herniated nucleus pulposus (HNP). This is because displacement occurs when the inner gel-like substance (nucleus pulposus) of the intervertebral disc bulges out from or herniates through the outer fibrous ring and into the spinal canal. The herniated or displaced nucleus pulposus may then press on spinal nerves causing pain or other sensory disturbances, such as tingling or numbness, as well as changes in motor function and reflexes.
In ICD-10-CM, category M50 contains codes for cervical disc disorders with sites specific to the high cervical region, midcervical region redefined for October 1, 2016 by disc space level (C4-C5, C5-C6, C6-C7), and cervicothoracic region. Category M51 contains codes for disc disorders of the thoracic, thoracolumbar, lumbar, and lumbosacral regions. In addition to codes specific to these sites, combination codes identify disc disorders as with myelopathy or with radiculopathy. There are also codes for other disc displacement, other disc degeneration, other cervical disc disorders, and unspecified disc disorders. Documentation must clearly describe the specific condition and any associated myelopathy or radiculopathy to ensure that the most specific code is assigned.
Coding and Documentation Requirements
Identify condition:
•Disc disorder
–Identify symptom
»with myelopathy
»with radiculopathy
•Other disc displacement
•Other disc degeneration
•Other disc disorders
•Schmorl’s nodes
•Unspecified disc disorder
Identify site:
•Cervical
–Identify level
»High cervical (C2-C4)
»Mid-cervical (C4-5, C5-6, C6-7)
»Cervicothoracic (C7-T1)
•Thoracic region
•Thoracolumbar region (T10-L1)
•Lumbar region
•Lumbosacral region
•Unspecified site
Note: In ICD-10-CM, codes for “other” disc displacement, degeneration, disorder are used for the specified condition when there is no documentation of either myelopathy or radiculopathy. If disc displacement, degeneration, or disorder are documented as with myelopathy or with radiculopathy, the codes for disc disorder with myelopathy or disc disorder with radiculopathy are reported.
Cervical Intervertebral Disc Disorders
ICD-10-CM Code/Documentation |
M50.20 |
Other cervical disc displacement, unspecified cervical region |
M50.21 |
Other cervical disc displacement, high cervical region |
M50.220 |
Other cervical disc displacement, mid-cervical region, unspecified level |
M50.221 |
Other cervical disc displacement at C4-C5 level |
M50.222 |
Other cervical disc displacement at C5-C6 level |
M50.223 |
Other cervical disc displacement at C6-C7 level |
M50.23 |
Other cervical disc displacement, cervicothoracic region |
M50.30 |
Other cervical disc degeneration, unspecified cervical region |
M50.31 |
Other cervical disc degeneration, high cervical region |
M50.320 |
Other cervical disc degeneration, mid-cervical region, unspecified level |
M50.321 |
Other cervical disc degeneration at C4-C5 level |
M50.322 |
Other cervical disc degeneration at C5-C6 level |
M50.323 |
Other cervical disc degeneration at C6-C7 level |
M50.33 |
Other cervical disc degeneration, cervicothoracic region |
M50.00 |
Cervical disc disorder with myelopathy, unspecified cervical region |
M50.01 |
Cervical disc disorder with myelopathy, high cervical region |
M50.020 |
Cervical disc disorder with myelopathy, mid-cervical region, unspecified level |
M50.021 |
Cervical disc disorder at C4-C5 level with myelopathy |
M50.022 |
Cervical disc disorder at C5-C6 level with myelopathy |
M50.023 |
Cervical disc disorder at C4-C5 level with myelopathy |
M50.03 |
Cervical disc disorder with myelopathy, cervicothoracic region |
M50.80 |
Other cervical disc disorders, unspecified cervical region |
M50.81 |
Other cervical disc disorders, high cervical region |
M50.820 |
Other cervical disc disorders, mid-cervical region, unspecified level |
M50.821 |
Other cervical disc disorders at C4-C5 level |
M50.822 |
Other cervical disc disorders at C5-C6 level |
M50.823 |
Other cervical disc disorders at C6-C7 level |
M50.83 |
Other cervical disc disorders, cervicothoracic region |
M50.90 |
Cervical disc disorder, unspecified, unspecified cervical region |
M50.91 |
Cervical disc disorder, unspecified, high cervical region |
M50.920 |
Unspecified cervical disc disorder, mid-cervical region, unspecified level |
M50.921 |
Unspecified cervical disc disorder at C4-C5 level |
M50.922 |
Unspecified cervical disc disorder at C5-C6 level |
M50.923 |
Unspecified cervical disc disorder at C6-C7 level |
M50.93 |
Cervical disc disorder, unspecified, cervicothoracic region |
M50.10 |
Cervical disc disorder with radiculopathy, unspecified cervical region |
M50.11 |
Cervical disc disorder with radiculopathy, high cervical region |
M50.120 |
Mid-cervical disc disorder, unspecified level |
M50.121 |
Cervical disc disorder at C4-C5 level with radiculopathy |
M50.122 |
Cervical disc disorder at C5-C6 level with radiculopathy |
M50.123 |
Cervical disc disorder at C6-C7 level with radiculopathy |
M50.13 |
Cervical disc disorder with radiculopathy, cervicothoracic region |
M54.11 |
Radiculopathy, occipito-atlanto-axial cervical region |
M54.12 |
Radiculopathy, cervical region |
M54.13 |
Radiculopathy, cervicothoracic region |
Documentation and Coding Example
Thirty-three-year-old Caucasian female is referred to Neurology Clinic by PMD for right arm pain and weakness. Patient is a NICU RN working 3-5 twelve-hour shifts/wk. primarily with premature infants. She can recall no injury to her neck or arm but simply awoke two weeks ago with a sharp pain that radiated through her shoulder, down her right arm to the tip of her thumb. She is left hand dominant. The pain is resolving but she continues to have weakness, numbness, and tingling in the arm. She treated her symptoms with rest, heat, and ibuprofen during 2 regularly scheduled days off and was able to return to work for her next scheduled shift. She was concerned about the residual weakness in her arm and called her PMD who ordered cervical spine films and an MRI which showed disc displacement/protrusion at C5-C6. He prescribed oral steroids and Tramadol for pain, Lunesta for sleep and referred her to Neurology. On examination, this is a moderately obese woman who looks her stated age. PERRL, there is stiffness and decreased ROM in her neck, cranial nerves grossly intact. Exam of left upper extremity is unremarkable with intact pulses, reflexes, ROM and strength. Exam of right arm is significant for moderate weakness in the right bicep muscle and wrist extensor muscles. Sensation to both dull and sharp stimuli is decreased along the anterior right arm beginning at shoulder to mid forearm level. Pincher grasp is weak on the right. Pulses are intact as are reflexes. MRI is reviewed with patient and she does indeed have a small herniation of the disc at C5-C6 space which is most likely the cause of her current myelopathy. She is advised to stop taking the Lunesta and Tramadol and is prescribed Celebrex and acetaminophen for pain. PT agrees to see her this afternoon for initial evaluation, possible soft cervical collar. She is cleared to work as long as she does not lift more than 10 lbs. RTC in 2 weeks for recheck.
Diagnosis Code(s)
M50.022 |
Cervical disc disorder at C5-C6 level with myelopathy |
Coding Note(s)
To identify the correct code, instructions in the Alphabetic Index are followed. Under Displacement, intervertebral disc, with myelopathy there is an instruction, see Disorder, disc, cervical, with myelopathy. Code M50.022 is identified as the correct code for Disorder, disc, with myelopathy, C5-C6.
Limb pain
The cause of pain in a limb may not be readily evident. Often several conditions must be worked up and ruled out before a definitive diagnosis can be made. In the outpatient setting, conditions that are documented as possible or to be ruled-out cannot be listed as confirmed diagnoses. A non-specific symptom code is reported until the underlying cause of the pain has been diagnosed. Codes for limb pain refer to pain that is not located in the joint. There are more specific codes for joint pain. Limb pain would not be assigned if a known cause exists such as mononeuritis or neuralgia which would be reported with codes from the nervous system chapter. Limb pain is captured by codes in subcategory M79.6. The pain needs to be defined by the specific site and laterality. Details of documentation requirements are listed below.
Coding and Documentation Requirements
Identify site of pain:
•Upper extremity
–Upper arm
–Forearm
–Hand
–Finger(s)
–Site not specified
•Lower extremity
–Thigh
–Lower leg
–Foot
–Toe(s)
–Site not specified
•Unspecified limb
For upper and lower extremity, identify laterality
•Right
•Left
•Unspecified
There are codes for unspecified limb (not specified as upper or lower); unspecified arm (site not specified and not specified as right or left); unspecified leg (site not specified and laterality not specified). There are also codes for specified site but unspecified laterality for upper arm, forearm, hand, fingers, thigh, lower leg, foot, and toes. However, even though codes for unspecified limb and unspecified laterality are provided, they should be avoided as the specific limb affected and laterality should always be documented.
ICD-10-CM Code/Documentation |
Pain in Limb, Unspecified |
M79.601 |
Pain in right arm |
M79.602 |
Pain in left arm |
M79.603 |
Pain in arm, unspecified |
M79.604 |
Pain in right leg |
M79.605 |
Pain in left leg |
M79.606 |
Pain in leg, unspecified |
M79.609 |
Pain in unspecified limb |
Pain in Upper Arm/Forearm/Hand/Fingers |
M79.621 |
Pain in right upper arm |
M79.622 |
Pain in left upper arm |
M79.629 |
Pain in unspecified upper arm |
M79.631 |
Pain in right forearm |
M79.632 |
Pain in left forearm |
M79.639 |
Pain in unspecified forearm |
M79.641 |
Pain in right hand |
M79.642 |
Pain in left hand |
M79.643 |
Pain in unspecified hand |
M79.644 |
Pain in right finger(s) |
M79.645 |
Pain in left finger(s) |
M79.646 |
Pain in unspecified fingers |
Pain in Thigh/Lower Leg/Foot/Toes |
M79.651 |
Pain in right thigh |
M79.652 |
Pain in left thigh |
M79.659 |
Pain in unspecified thigh |
M79.661 |
Pain in right lower leg |
M79.662 |
Pain in left lower leg |
M79.669 |
Pain in unspecified lower leg |
M79.671 |
Pain in right foot |
M79.672 |
Pain in left foot |
M79.673 |
Pain in unspecified foot |
M79.674 |
Pain in right toe(s) |
M79.675 |
Pain in left toes(s) |
M79.676 |
Pain in unspecified toe(s) |
Documentation and Coding Example
Twenty-five-year-old Hispanic male presents to Urgent Care Clinic with a four-day history of pain and swelling in left forearm. Patient is in good health and does not have a PMD, the last time he sought medical care was in college. He is employed full time developing computer software. He works from home most of the time, flying into the company’s central office for a few days each month. His arm pain started on the last day of a 5-day trip to the central office. He can recall no injury although he did engage in daily, strenuous physical activities including ultimate Frisbee, volleyball, and basketball. Pain began as a dull ache in the inner arm midway between elbow and wrist. Upon returning home, he continues to experience a dull ache in the forearm which varies in intensity but is always present. He has applied ice to the area off and on for the past 2 days. This morning the remains achy so he seeks medical attention. On examination, this is a well-groomed, well nourished, somewhat anxious young man. T 98.5, P 60, R 12, BP 104/54, O2 Sat 99% on RA. Eyes clear, PERRLA. Nares patent, mucous membranes moist and pink, TMs normal. Neck supple without masses or lymphadenopathy. Cranial nerves grossly intact. Heart rate regular, breath sounds clear, equal bilaterally. Abdomen soft, non-tender with active bowel sounds. No evidence of hernia, normal male genitalia. Examination of lower extremities is completely benign. Right upper extremity has normal strength, sensation and movement. Left upper arm has normal tone, strength, reflexes, sensation and circulation. The left elbow is unremarkable with normal ROM. The inner forearm is palpated. No mass or other signs of abnormality are noted other than the dull aching pain. Negative for Raynaud phenomena. Circulation and sensation intact through fingers. Supination and pronation exacerbates the pain as does fist clenching. X-ray of forearm is obtained and is negative for fracture.
Impression: Pain left forearm of unknown etiology.
Plan: Blood drawn for CBC w/diff, ESR, CRP, Quantitative Immunoglobulin levels, comprehensive metabolic panel. Results will be forwarded to Internal Medicine Department where he has an appointment scheduled in 3 days. He is fitted with a sling to be used PRN for comfort. He is advised to use ibuprofen for pain and to return to Urgent Care Clinic if symptoms worsen before his appointment with Internist.
Diagnosis Code(s)
M79.632 |
Pain in left forearm |
Coding Note(s)
Pain of unknown etiology is specific to site and laterality.
Lumbago/Sciatica
Lumbago refers to non-specific pain in the lower back region. The condition is very common and may be acute, subacute, or chronic in nature. Lumbago is generally a symptom of benign musculoskeletal strain or sprain with no underlying disease or syndrome.
Sciatica is a set of symptoms characterized by pain, paresthesia (shock like pain in the arms and/or legs), and/or weakness in the low back, buttocks, or lower extremities. Symptoms result from compression of one or more spinal nerves (L4, L5, S1, S2, S3) that form the sciatic nerve (right and left branches). Causes can include herniated discs, spinal stenosis, pregnancy, injury or tumors.
In ICD-10-CM, there is a code for lumbago alone designated by the descriptor low back pain (M54.5). There are also codes for sciatica alone (M54.3-) and a combination code for lumbago with sciatica (M54.4-). Codes for sciatica require documentation of laterality to identify the side of the sciatic nerve pain.
Coding and Documentation Requirements
Identify the low back pain/sciatica:
•Low back pain
–With sciatica
»Right side
»Left side
»Unspecified side
–Without sciatica
•Sciatica
–Right side
–Left side
–Unspecified side
ICD-10-CM Code/Documentation |
M54.5 |
Low back pain |
M54.30 |
Sciatica, unspecified side |
M54.31 |
Sciatica, right side |
M54.32 |
Sciatica, left side |
M54.40 |
Lumbago with sciatica, unspecified side |
M54.41 |
Lumbago with sciatica, right side |
M54.42 |
Lumbago with sciatica, left side |
Documentation and Coding Example
Forty-two-year-old female presents to PMD with ongoing sharp pain in her left buttocks radiating down the back of her left leg. She states the pain began suddenly about 1 week ago as she was preparing and planting her Spring garden. She does not recall any specific injury only that she was hauling bags of soil and compost mix, bending a lot and on her knees weeding and planting. On examination, this is a very pleasant, quite tan, well developed, well-nourished woman who looks older than her stated age. She states she loves to be outdoors and never applies sunscreen, believing that sun exposure is healthy for her body. Cranial nerves grossly intact. Neurovascular exam of upper extremities is unremarkable. Thoracic spine is straight without swelling or tenderness to palpation. There is mild tenderness with palpation of her lumbar spine and moderate muscle spasm with deep palpation of her left buttocks. Forward bending elicits pain at the thoracolumbar junction. Leg lifts also elicit pain on the left. Patient states pain and stiffness is worse on rising in the morning, decreases when lying down and changes from sharp pain to dull ache when sitting. Patient declines x-ray of her spine as she believes radiation is harmful to her body. She declines prescriptions for pain medication, muscle relaxant, or NSAIDs. She is using topical arnica gel and an oral homeopathic for inflammation. She is agreeable to physical therapy for muscle flexibility and strengthening exercises. She is given a written prescription for PT because she would like to do some research and find a therapist who would be a good fit for her. RTC in 6 weeks, sooner if needed.
Impression: Left sciatica with low back pain.
Diagnosis Code(s)
M54.42 |
Lumbago with sciatica, left side |
Coding Note(s)
There is a combination code for lumbago with sciatica is reported. Codes for sciatica and lumbago with sciatica are specific to the side of the sciatic pain. The physician has documented that the patient is experiencing left-sided sciatica.
Osteoarthritis
There are multiple codes in multiple code categories for osteoarthritis (M15, M16, M17, M18, and M19). These codes are to be used for osteoarthritis of extremity joints. Codes for osteoarthritis of the spine will be located in category M47. There are specific codes for primary and secondary arthritis with the codes for secondary arthritis being specific for post-traumatic osteoarthritis and other secondary osteoarthritis. It is important to note that there are also codes for post-traumatic arthritis, M12.5- that are not osteoarthritis. It is imperative that the documentation specifies whether the arthritis resulting from trauma is post-traumatic degenerative which is usually a result of trauma surrounding the joint such as following multiple ankle sprains vs. post-traumatic which is due to trauma involving the joint surface such as following a tibial pilon fracture. For secondary osteoarthritis of the hip there is also a specific code for osteoarthritis resulting from hip dysplasia. Codes for specific types of osteoarthritis require laterality (right, left). For the hip, knee and first CMC joint there are also bilateral codes. Codes for other secondary arthritis of the hip and knee must be specified as either bilateral or unilateral, but there are not specific codes for right and left. Unspecified osteoarthritis does not require any information on laterality. An additional category is available for polyosteoarthritis, category M15. This involved osteoarthritis of more than five joints and includes such disorders as Heberden’s nodes and Bouchard’s notes of the hands as well as primary generalized osteoarthritis. Bilateral osteoarthritis of a single joint should not be coded as polyosteoarthritis or generalized osteoarthritis.
Coding and documentation requirements for osteoarthritis are provided followed by a clinical example for osteoarthritis of the hip.
Coding and Documentation Requirements
Identify type of osteoarthritis:
•Primary
•Secondary
–Post-traumatic
–Resulting from hip dysplasia (hip only)
–Other specified secondary osteoarthritis
–Unspecified
Identify site:
•Hip
•Knee
•First carpometacarpal joint
•Shoulder
•Elbow
•Wrist
•Hand
•Ankle and foot
Identify laterality:
•Right
•Left
•Unspecified
Osteoarthritis of Hip
ICD-10-CM Code/Documentation |
M16.0 |
Bilateral primary osteoarthritis of hip |
M16.10 |
Unilateral primary osteoarthritis, unspecified hip |
M16.11 |
Unilateral primary osteoarthritis, right hip |
M16.12 |
Unilateral primary osteoarthritis, left hip |
M16.2 |
Bilateral osteoarthritis of hip resulting from hip dysplasia |
M16.30 |
Unilateral osteoarthritis of hip resulting from hip dysplasia, unspecified hip |
M16.31 |
Unilateral osteoarthritis of hip resulting from hip dysplasia, right hip |
M16.32 |
Unilateral osteoarthritis of hip resulting from hip dysplasia, left hip |
M16.4 |
Bilateral post-traumatic osteoarthritis of hip |
M16.50 |
Unilateral post-traumatic osteoarthritis, unspecified hip |
M16.51 |
Unilateral post-traumatic osteoarthritis, right hip |
M16.52 |
Unilateral post-traumatic osteoarthritis, left hip |
M16.6 |
Other bilateral secondary osteoarthritis of hip |
M16.7 |
Other unilateral secondary osteoarthritis of hip |
M16.9 |
Osteoarthritis of hip, unspecified |
Documentation and Coding Example
Sixty-one-year-old Caucasian female is referred to orthopedic clinic by PMD for ongoing right hip pain and stiffness. Patient sustained a soft tissue injury to her right hip and leg 6 years ago in a bicycle accident. X-rays at the time showed no fracture and she was treated conservatively with rest, ice and ibuprofen. She was able to return to her usual active lifestyle within a few weeks but over the years she has noticed increased stiffness, especially in the morning and she is taking acetaminophen for pain 4-5 times a week. On examination, this is a trim, fit appearing woman who looks younger than her stated age. Gait is normal. There is no evidence of osteophytic changes to small joints. Patient denies fatigue, weight loss or fevers. Cranial nerves grossly intact, neuromuscular exam of upper extremities is unremarkable. Muscle strength equal in lower extremities, there is marked tenderness with palpation of the right hip, no swelling, muscle wasting or crepitus. X-ray obtained of bilateral hips for comparison. Left hip x-ray and exam is relatively benign. Radiograph of right hip is significant for sclerosis of the superior aspect of the acetabulum along with single Egger cyst. Findings are consistent with post-traumatic osteoarthritis of the hip. Treatment options discussed with patient and she prefers a conservative plan at this time. She is referred to physical therapy 3 x week for 4 weeks and advised to take Naproxen sodium 220 mg BID. RTC in one month for re-evaluation.
Diagnosis Code
M16.51 |
Unilateral post-traumatic osteoarthritis, right hip |
Coding Note(s)
The ICD-10-CM code identifies the secondary osteoarthritis as post-traumatic and is also specific to site (hip) and laterality (right).
An external cause code is not required but if the documentation was sufficient on the circumstances of the accident an external cause code could also be reported to identify the cause of the post-traumatic osteoarthritis as a bicycle accident.
Osteoporosis
Osteoporosis is a systemic disease that affects previously constructed bone tissue. It is characterized by decreased bone density, weakness, and brittleness, making the bone more susceptible to fracture. Primary type 1 (postmenopausal) osteoporosis typically affects women after menopause. Primary type 2 (senile) osteoporosis is identified in both men and women after the age of 75. Secondary osteoporosis can occur in either sex and at any age. It arises from an underlying medical condition, prolonged immobilization or the use of certain drugs that affect mineral balance in the bones. With any type of osteoporosis, the most common bones affected are vertebrae, ribs, pelvis, and upper extremities. The condition is often asymptomatic until a fracture occurs.
In ICD-10-CM, there are two categories for osteoporosis. Codes from category M80 are reported for osteoporosis with a current pathological fracture and codes from M81 are reported for osteoporosis without a current pathological fracture. Osteoporosis with or without pathological fracture is then subclassified as age-related or other specified type, which includes drug-induced, disuse, idiopathic, post-oophorectomy, postsurgical malabsorption, and post-traumatic osteoporosis. There is no code for unspecified osteoporosis. If documentation does not identify a specific type or cause of osteoporosis, the Alphabetic Index directs to ‘age-related’. If the osteoporosis is associated with a current fracture, the fracture site and laterality must be documented. In addition, osteoporosis codes with a current pathological fracture require a 7th character to identify the episode of care.
The applicable 7th character extensions for osteoporosis with pathological fracture are as follows:
AInitial encounter for fracture
DSubsequent encounter for fracture with routine healing
GSubsequent encounter for fracture with delayed healing
KSubsequent encounter for fracture with nonunion
PSubsequent encounter for fracture with malunion
SSequela
Coding and Documentation Requirements
Identify osteoporosis as with or without current pathological fracture:
•With current pathological fracture
•Without current pathological fracture
Identify type/cause of osteoporosis:
•Age-related
•Localized
•Other
For osteoporosis with current pathological fracture, identify site of fracture:
•Shoulder
•Humerus
•Forearm
•Hand
•Femur
•Lower leg
•Ankle/foot
•Vertebra(e)
•Other site
Identify episode of care:
•Initial encounter
•Subsequent encounter
–With routine healing
–With delayed healing
–With nonunion
–With malunion
•Sequela
Senile/Age-Related Osteoporosis with Current Pathological Fracture of Forearm/Wrist
ICD-10-CM Code/Documentation |
M80.031- |
Age related osteoporosis with current pathological fracture, right forearm |
M80.032- |
Age related osteoporosis with current pathological fracture, left forearm |
M80.039- |
Age related osteoporosis with current pathological fracture, unspecified forearm |
Note: Requires 7th character to identify episode of care. |
Documentation and Coding Example
Fifty-nine-year-old Caucasian female returns to Orthopedic Clinic for a second postoperative visit. She is now five weeks S/P fall at home where she sustained a fracture of the distal right radius. She presented initially to the ED with pain, swelling and deformity of the right wrist and forearm with tenderness and swelling of the distal radius. Radiographs showed a distal radial fracture and severe osteoporosis of the radius and ulna. She underwent an ORIF that same day with application of soft cast/splint. She had a hard cast applied at her first PO visit 3 weeks ago. Patient states she is doing well and has no complaints. Bruising and swelling have subsided in her fingers and she has good ROM and neurovascular checks. She admits to mild pain, usually associated with over use, that is relieved with acetaminophen. X-ray in plaster shows the fracture to be in good alignment with increased callus size when compared to previous film. She is taking a Calcium supplement, Vitamin D 6000 units, Vitamin C 1000 mg daily and a multivitamin/mineral tablet. Patient is advised to continue with her present supplements. RTC in 3 weeks for x-ray out of plaster and application of splint. Patient is due for annual physical exam with her PCP in 3 months. She is advised to discuss having a DEXA scan to assess bone density since it has been 6 years since her last one and she has now entered menopause. Once they have those results she may need to consider more aggressive therapy for her osteoporosis.
Impression: Healing distal radial fracture right forearm. Fracture due to postmenopausal osteoporosis. S/P ORIF.
Diagnosis Code(s)
M80.031D |
Age related osteoporosis with current pathological fracture, right forearm, subsequent encounter for fracture with routine healing |
W19.XXXD |
Unspecified fall, subsequent encounter |
Coding Note(s)
Even though the fracture was sustained in a fall, ICD-10-CM coding guidelines state, “A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone.” An external cause code may be reported additionally to identify the pathological fracture as due to a fall. An unspecified fall is reported because the documentation does not provide any information on circumstances surrounding the fall, such as a fall due to tripping or a fall from one level to another. The 7th character D is assigned to identify this encounter as a subsequent visit for aftercare.
Radiculopathy
Neuritis is a general term for inflammation of a nerve or group of nerves. Symptoms will vary depending on the area of the body and the nerve(s) that are inflamed. Symptoms may include pain, tingling (paresthesia), weakness (paresis), numbness (hypoesthesia), paralysis, loss of reflexes, and muscle wasting. Causes can include injury, infection, disease, exposure to chemicals or toxins, and nutritional deficiencies.
Radiculitis is a term used to describe pain that radiates along the dermatome (sensory pathway) of a nerve or group of nerves and is caused by inflammation or irritation of the nerve root(s) near the spinal cord. Symptoms vary depending on the exact nerve root(s) affected, but can include pain with a sharp, stabbing, shooting or burning quality; tingling (paresthesia); numbness (hypoesthesia); weakness (paresis); loss of reflexes; and muscle wasting. Causes can include injury, anatomic abnormality (e.g., bone spur), degenerative disease, and bulging or ruptured intervertebral disc.
Neuralgia, neuritis, and radiculitis of unknown cause are reported with “not otherwise specified” codes. There are two subcategories, M54.1 Radiculopathy, which is specific to neuritis and radiculitis of a specific spinal level and M79.2 Neuralgia and neuritis unspecified.
Coding and Documentation Requirements
Identify site of neuritis/radiculitis:
•Occipito-atlanto-axial region
•Cervical region
•Cervicothoracic region
•Thoracic region
•Thoracolumbar region
•Lumbar region
•Lumbosacral region
•Sacral/sacrococcygeal region
•Unspecified site
–Radiculitis
–Neuritis/neuralgia
ICD-10-CM Code/Documentation |
M54.11 |
Radiculopathy, occipito-atlanto-axial region |
M54.12 |
Radiculopathy, cervical region |
M54.13 |
Radiculopathy, cervicothoracic region |
M54.14 |
Radiculopathy, thoracic region |
M54.15 |
Radiculopathy, thoracolumbar region |
M54.18 |
Radiculopathy, lumbar region |
M54.17 |
Radiculopathy, lumbosacral region |
M54.10 |
Radiculopathy, site unspecified |
M54.18 |
Radiculopathy, sacral and sacrococcygeal region |
M79.2 |
Neuralgia and neuritis, unspecified |
Documentation and Coding Example
Fifty-five-year-old Caucasian female presents to PMD with tingling and numbness in the labia/perineal area, right buttocks and back of right thigh X 2 months with weakness in the right leg for the past few days. Patient is divorced, her youngest son is living with his father and older son has moved out of state to attend school. She continues to work part time as an office assistant. She sits a lot for her job but is quite active outside of work. She regularly hikes and bikes, plays softball, bowls and swims. She can recall no injury or trauma to her back or legs, simply noticed tingling and numbness sitting on the seat of her bike one day. HT 70 inches, WT 138, T 99, P 66, R 14, BP 124/62. On examination, this is a pleasant, thin, athletic appearing woman who looks her stated age. Eyes clear, PERRLA. TMs normal, nares patent without drainage. Oral mucosa moist and pink. Neck supple without lymphadenopathy. Cranial nerves grossly intact. Upper extremities normal. HR regular without bruit, rub or murmur. Breath sounds clear and equal bilaterally. Abdomen soft with active bowel sounds. Last gynecological exam was 8 months ago and completely normal. LMP 14 days ago, periods are for the most part regular at an interval of 23-24 days. She is S/P left salpingectomy for ectopic pregnancy 15 years ago with tubal ligation on the right at the time of that surgery. Patient is sexually active with her boyfriend and reports no change in libido or diminished pleasure from intercourse. There have been no changes in her bowel or bladder habits. She has trouble discerning both sharp and dull sensation on the labia from the level of the urethral meatus through the perineum and anus, extending to the right buttocks and mid posterior right thigh. Tone is 5/5 on left leg, 4/5 on right with 3+ reflexes on left and 2+ on right. Mild, intermittent muscle fasciculation noted in right buttocks. No muscle atrophy, rigidity, resistance or tenderness noted in lower extremities. She has difficulty maintaining leg lift on right with very mild drift from midline. Gait is normal.
Impression: Radiculitis, sacral region.
Plan: MRI of lumbar spine and sacrum is scheduled. Patient is instructed to have fasting blood drawn for CBC w/diff, comprehensive metabolic panel, Thyroid panel, Lipid panel, Vitamin D3, Vitamin B panel. Follow up appointment in 1 week to review test results. Consider referral to neurologist for EMG at that time.
Diagnosis Code(s)
M54.18 |
Radiculopathy, sacral and sacrococcygeal region |
Coding Note(s)
To identify radiculitis, instructions in the Alphabetic Index under radiculitis state to see radiculopathy. Under radiculopathy, the code is found based upon the location or causation. There is a specific code for radiculopathy of the sacral and sacrococcygeal region.
Rupture of Tendon, Nontraumatic
Nontraumatic ruptures of tendons occur most often in the elderly, particularly in patients with other risk factors such as corticosteroid use and/or use of certain antibiotics, particularly quinolones. Codes are specific to site, such as shoulder, upper arm, forearm, hand, thigh, lower leg, ankle and foot; and to action such as extensor, flexor, and other tendon. Because physicians may name the tendon, such as Achilles, and not the specific site and action such as lower leg flexor tendon, coders must become familiar with the muscles and tendons of the extremities and their action in order to assign the nontraumatic tendon rupture to the correct code. Muscles and tendon names are frequently based upon their action and location. Some of the terms related to muscles and tendons are listed below.
Abductor/Abduction – Abductor muscle(s) work to move a body part away from the midline (e.g., raising the arm).
Adductor/Adduction – Adductor muscle(s) work to bring a body part closer to the midline.
Circumduction – Circular or conical motion movement of a joint due to a composite action of flexion, abduction, extension and adduction in that order.
Dorsiflexion – Muscle(s) work to tip the upper surface of the foot (dorsum) toward the anterior leg, decreasing the angle between the foot and leg.
Elevation/Depression – Muscle(s) work to raise (elevate) a body part to a more superior level (shoulder shrug), then lower that body part to a more inferior position (depression).
Eversion/Inversion – Muscles work to obliquely rotate the foot along the medial side of the heel to the lateral side of the mid foot. With inversion, the sole of the foot is turned inward toward the opposite foot and in eversion, the sole of the foot is turned outward and away from the midline.
Extensor/Extension – An extensor muscle works to increase the angle between bones that converge at a joint. For example: straightening the elbow or knee and bending the wrist or spine backward. Muscles of the hand and foot often contain this function in their name (example: extensor digitorum).
Flexor/Flexion – A flexor muscle works to decrease the angle between bones that converge at a joint, for example bending the elbow or knee. Muscles of the hand and foot may contain this function in their name (example: flexor carpi radialis, flexor hallucis longus).
Insertion – Attachment of the muscle or tendon to the skeletal area that the muscle moves when it contracts. The location is usually more distal on the bone with greater mobility and less mass when compared to the muscle origin point.
Opposition – Special muscle action of the hand in which the carpal/metacarpal bones in the thumb and fingers allow them to come together at their fingertips.
Origin – Muscle origin is the fixed attachment of muscle to bone. The location is usually more proximal on the bone with greater stability and mass when compared to the muscle insertion site allowing the muscle to exert power when it contracts.
Plantar Flexion – Muscle(s) work to tip the lower surface of the foot (sole, plantar area) downward, increasing the angle between the foot and anterior leg.
Pronation/Supination – Special muscle action of the forearm in which the radius crosses over the ulna resulting in the dorsal surface of the hand turning forward or prone (pronation, palm down). When the radius uncrosses, the palmer surface of the hand returns to its normal supine forward position (supination, palm up).
Protraction/Retraction – Muscle(s) work to move a body part forward (protraction), for example hunching of shoulders, then backward (retraction) when shoulders are squared.
Rotation – A movement that occurs around the vertical or longitudinal axis moving the body part toward or away from the center axis. Lateral/external rotation moves the anterior surface away from the midline. Medial/internal rotation moves the anterior surface toward the midline of the body.
The table below identifies a number of specific muscles and tendons of the extremities, the location of the muscle (e.g., upper/lower extremity, upper/lower leg, upper/lower arm), a brief description of the muscle or tendon, the origin and insertion, and the action. When coding it is important to know the location of the rupture since many muscles/tendons cover multiple sites. The table is organized alphabetically by tendon/muscle. Following the table is a documentation and coding example.
Muscle/Tendon |
Location |
Origin (O)/Insertion (I) |
Action |
Abductor pollicis brevis |
Wrist/Hand/Thumb |
O: Transverse carpal ligament and the tubercle of the scaphoid bone or (occasionally) the tubercle of the trapezium
I: Base of the proximal phalanx of the thumb |
Abducts the thumb and with muscles of the thenar eminence, acts to oppose the thumb |
Abductor pollicis longus (APL) |
Forearm/Thumb/Hand/Wrist |
O: Posterior radius, posterior ulna and interosseous membrane
I: Base 1st metacarpal
Combined with the extensor pollicis brevis makes the anatomic snuff box. |
Abducts and extends thumb at CMC joint; assists wrist abduction (radial deviation) |
Achilles tendon |
Lower Leg |
O: Joins the gastrocnemius and soleus muscles
I: Calcaneus |
Flexor tendon – plantar flexes foot |
Anconeus |
Elbow |
O: Lateral epicondyle humerus
I: Posterior olecranon |
Extends forearm |
Brachialis |
Elbow |
O: Distal ½ anterior humeral shaft
I: Coronoid process and ulnar tuberosity |
Flexes forearm |
Biceps brachii |
Shoulder/Upper Arm |
Long Head:
O: Supraglenoid tubercle of the scapula to join the biceps tendon, short head in the middle of the humerus forming the biceps muscle belly
Short Head:
O: Coracoid process at the top of the scapula
I: Radial tuberosity
Long head and short head join in the middle of the humerus forming the biceps muscle belly |
Flexes elbow
Supinates forearm
Weakly assists shoulder with forward flexion (long head)
Short head provides horizontal adduction to stabilize shoulder joint and resist dislocation.
With elbow flexed becomes a powerful supinator |
Common flexor tendon |
Forearm/Hand |
Common flexor tendon formed by 5 muscles of the forearm. There are slight variations in the site of origin and insertion |
|
1.Pronator teres |
|
1.O: Medial epicondyle humerus and coronoid process of the ulna. I: Mid-lateral surface radial shaft |
1.Pronator Teres-pronation of forearm; assists elbow flexion |
2.Flexor carpi radialis (FCR) |
|
2.O: Medial epicondyle humerus.
I: Base of 2nd and 3rd metacarpal |
2.FCR- flexion and abduction of wrist (radial deviation) |
3.Palmaris longus |
|
3.O: Medial epicondyle humerus.
I: Palmar aponeurosis and flexor retinaculum |
3.Palmaris longus-assists wrist flexion |
4.Flexor digitorum superficialis (sublimis) (FDS) |
|
4.O: Medial epicondyle humerus, coronoid process ulna and anterior oblique line of radius. I: shaft middle phalanx digits 2-5 |
4.FDS- flexion middle phalanx PIP joint digits 2-4; assists wrist flexion |
5.Flexor carpi ulnaris (FCU) |
|
5.O: Medial epicondyle of the humerus, olecranon and posterior border ulna
I: Pisiform, hook of hamate and 5th metacarpal. |
5.FCU- flexes and adducts hand at the wrist |
Coracobrachialis |
Shoulder/Upper Arm |
O: Coracoid process
I: Midshaft of humerus |
Adducts & flexes shoulder |
Deltoid |
Shoulder/Upper Arm |
O: Lateral 1/3 of clavicle, acromion and spine of scapula
I: Deltoid tuberosity of humerus
Large triangular shaped muscle composed of three parts |
Anterior-Flex & medially rotate shoulder; Middle-assist w/abduction of humerus at shoulder; Posterior-extend & laterally rotate humerus |
Extensor carpi radialis longus (ECRL) |
Forearm/Hand |
O: Lateral epicondyle humerus
I: Dorsal surface 2nd metacarpal |
Extends and abducts wrist; active during fist clenching |
Extensor (digitorum) communis (EDC) |
Forearm/Wrist/Hand/Finger |
O: Lateral epicondyle humerus terminates into 4 tendons in the hand
I: On the lateral and dorsal surfaces of digits 2-5 (fingers) |
Extends the metacarpophalangeal (MCP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints of 2nd-5th fingers and wrist |
Extensor digitorum longus (EDL) |
Lower Leg/Ankle/Foot |
O: Lateral condyle tibia, proximal 2/3 anterior fibula shaft and interosseous membrane
I: Middle and distal phalanx toes 2-5 |
Extension lateral 4 digits at metatarsophalangeal joint; assists dorsiflexion of foot at ankle |
Extensor hallicus longus (EHL) |
Lower Leg/Ankle/Foot |
O: Middle part anterior surface fibula and interosseous membrane
I: Dorsal aspect base distal phalanx great toe |
Extends great toe; assists dorsiflexion of foot at ankle; weak invertor |
Extensor pollicis brevis (EPB) |
Wrist/Hand/Thumb |
O: Distal radius (dorsal surface) and interosseous membrane
I: Base proximal phalanx thumb
Combined with the abductor pollicis longus makes the anatomic snuff box |
Extends the thumb at metacarpophalangeal joint (MCPJ) |
Extensor pollicis longus (EPL) |
Wrist/Hand/Thumb |
O: Dorsal surface of the ulna and interosseous membrane
I: Base distal phalanx thumb |
Extends distal phalanx thumb at IP joint; assists wrist abduction |
Flexor digitorum longus (FDL) |
Lower Leg/Ankle/Foot |
O: Medial posterior tibia shaft
I: Base distal phalanx digits 2-5 |
Flexes digits 2-5; plantar flex ankle; supports longitudinal arch of foot |
Flexor digitorum profundus (FDP) |
Forearm/Wrist/Hand |
O: Proximal 1/3 anterior-medial surface ulna and interosseous membrane; in the hand splits into 4 tendons
I: Base of the distal phalanx, digits 2-5 (fingers) |
Flexes the distal phalanx, digits 2-5 (fingers) |
Flexor hallucis longus (FHL) |
Lower Leg/Ankle/Foot |
O: Inferior 2/3 posterior fibula; inferior interosseous membrane
I: Base distal phalanx great toe (hallux) |
Flexes great toe at all joints; weakly plantar flexes ankle; supports medial longitudinal arches of foot |
Flexor pollicis brevis (FPB) |
Wrist/Hand/Thumb |
O: Distal edge of the transverse carpal ligament and the tubercle of the trapezium
I: Proximal phalanx of the thumb |
Flexes the thumb at the metacarpophalangeal (MCPJ) and carpometacarpal (CMC) joint |
Flexor pollicis longus (FPL) |
Forearm/Wrist/Hand/Thumb |
O: Below the radial tuberosity on the anterior surface of the radius and interosseous membrane
I: Base distal phalanx thumb |
Flexes the thumb at the metacarpophalangeal (MCPJ) and interphalangeal (IPJ) joint |
Hamstring |
Upper Leg/Knee |
Composed of three muscles |
|
|
|
1.Semitendinosus
O: Ischial tuberosity
I: Anterior proximal tibial shaft
Semimembranosus
O: Ischial tuberosity
I: Posterior medial tibial condyle |
1.Semitendinosus and Semimembranosus-Flexes leg at knee, when knee flexed medially rotates tibia; thigh extensor at hip joint; when hip & knee both flexed, extends trunk |
|
|
2.Biceps femoris
O: Long head ischial tuberosity; short head linea aspera femoral shaft and lateral supracondylar line
I: Head of fibula |
2.Biceps femoris-Flexes leg and rotates laterally when knee flexed; extends thigh |
Intrinsics of hand hypothenar |
Wrist/Hand/Finger |
|
|
1.Abductor digiti minimi |
|
1.O: Pisiform
I: Medial side of base proximal phalanx 5th finger |
1.Abducts 5th finger; assists flexion proximal phalanx |
2.Flexor digiti minimi brevis |
|
2.O: Hook of hamate & flexor retinaculum
I: Medial side of base proximal phalanx 5th finger |
2.Flexes proximal phalanx 5th finger |
3.Opponens digiti minimi |
|
3.O: Hook of hamate and transverse carpal ligament
I: Uulnar aspect shaft 5th metacarpal |
3.Rotates the 5th metacarpal bone forward |
Intrinsics of hand short |
Wrist/Hand |
|
|
1.Dorsal interossei 1-4 |
|
1.O: Adjacent sides of 2 MC
I: Bases of proximal phalanges; extensor expansions of 2-4 fingers |
1.Abduct 2-4 fingers from axial line; acts w/lumbricals to flex MCP jt and extend IP jt |
2.Dorsal interossei 1-3 |
|
2.O: Palmar surface 2nd, 4th & 5th MC
I: Bases of proximal phalanges; extensor expansions of 2nd, 4th & 5th fingers |
2.Adduct 2nd, 4th, 5th fingers from axial line; assist lumbricals to flex MCP jt and extend IP jt; extensor expansions of 2nd-4th fingers |
3.Lumbricals 1st & 2nd |
|
3.O: Lateral two tendons of FDP
I: Lateral sides of extensor expansion of 2nd-5th |
3.Flex MCP jt; extend IP joint 2-5 |
4.Lumbricals 3rd & 4th |
|
4.O: Medial 3 tendons of FDP
I: Lateral sides of extensor expansion of 2nd-5th |
4.Flex MCP jt; extend IP joint 2-5 |
Intrinsics of hand thenar |
Wrist/Hand/Thumb |
|
|
1.Abductor pollicis brevis |
|
1.O: Flexor retinaculum & tubercle scaphoid & trapezium
I: Lateral side of base of proximal phalanx thumb |
1.Abducts thumb; helps w/opposition |
2.Adductor pollicis |
|
2.O: Oblique head base 2nd & 3rd MC, capitate, adjacent carpals and transverse head anterior surface shaft 3rd MC
I: Medial side base of proximal phalanx thumb |
2.Adducts thumb toward lateral border of palm |
3.Flexor pollicis brevis |
|
3.O: Flexor retinaculum & tubercle scaphoid & trapezium
I: Lateral side of base of proximal phalanx thumb |
3.Flexes thumb |
4.Opponens pollicis |
|
4.O: Transverse carpal ligament and the tubercle of the trapezium
I: Lateral border shaft 1st metacarpal |
4.Rotates the thumb in opposition with fingers |
Lumbricals (foot) |
Foot |
O: Lumbricals-flexor digitorum longus tendon
I: Medial side base proximal phalanges 2-5 |
Assist in joint movement between metatarsals |
Patellar tendon |
Knee/Lower Leg |
Connects the bottom of the patella to the top of the tibia
The tendon is actually a ligament because it joins bone to bone |
Works with the quadriceps tendon to bend and straighten the knee |
Pectoralis major |
Chest/Upper Arm |
O: Clavicle, sternum, ribs 2-6
I: Upper shaft of humerus |
Adducts, flexes, medially rotates humerus |
Peroneus (fibularis) brevis |
Lower Leg/Ankle/Foot |
O: Distal 2/3 lateral shaft fibula
I: Becomes a tendon midcalf that runs behind the lateral malleolus inserts on tuberosity base 5th metatarsal |
Eversion of foot; assists with plantar flexion of foot at ankle |
Peroneus (fibularis) longus |
Lower Leg/Ankle/Foot |
O: Head and upper 2/3 lateral surface fibula
I: Becomes a long tendon midcalf that runs behind the lateral malleolus and crosses obliquely on plantar surface of foot inserts on base 1st metatarsal and medial cuneiform |
Eversion of foot; weak plantar flexion foot at ankle |
Peroneus (fibularis) tertius |
Lower Leg/Ankle/Foot |
O: Inferior 1/3 anterior surface fibula and interosseous membrane
I: Dorsum base 5th metatarsal |
Dorsiflexes ankle and aids inversion of foot |
Quadratus plantae |
Foot |
O: Calcaneus
I: Flexor digitorum tendons |
Assists flexor muscles |
Quadriceps femoris |
Upper Leg/Knee |
Composed of four muscles:
Rectus femoris
O: Anterior inferior iliac spine and ilium superior to acetabulum
I: Combines to form quadriceps tendon; inserts base of patella and tibial tuberosity via patellar ligament
Vastus lateralis
O: Greater trochanter and lateral aspect femoral shaft
I: Lateral patella and tendon of rectus femoris
Vastus medialis
O: Intertrochanteric line and medial aspect femoral shaft
I: Medial border of quadriceps tendon and medial aspect of patella; tibial tuberosity via patellar ligament
Vastus intermedius:
O: Anterior and lateral surface femoral shaft
I: Posterior surface upper border of patella; tibial tuberosity via patellar ligament |
Extends leg at knee joint; rectus femoris with iliopsoas helps flex thigh and stabilized hip joint |
Quadriceps tendon |
Upper Leg/Knee |
Fibrous band of tissue that connects the quadriceps muscle of the anterior thigh to the patella (kneecap) |
Holds the patella (kneecap) in the patellofemoral groove of the femur enabling it to act as a fulcrum and provide power to bend and straighten the knee |
Rotator cuff tendons: |
Shoulder/Upper Arm |
Rotator cuff tendons are formed by 4 muscles of the shoulder/upper arm. They all originate from the scapula and insert (terminate) on the humerus: |
|
1.Supraspinatus |
|
1.O: Supraspinous fossa of scapula.
I: Superior facet greater tuberosity humerus. |
1.Initiates abduction of shoulder joint (completed by deltoid) |
2.Infraspinatus |
|
2.O: Infraspinous fossa of scapula.
I: Middle facet greater tuberosity humerus. |
2.Externally rotates the arm; helps hold humeral head in glenoid cavity |
3.Teres minor |
|
3.O: Middle half of the lateral border of the scapula.
I: Inferior facet greater tuberosity humerus |
3.Externally rotates the arm; helps hold humeral head in glenoid cavity |
4.Subscapularis |
|
4.O: Subscapular fossa of scapula.
I: Either the lesser tuberosity humerus or the humeral neck. |
4.Internally rotates and adducts the humerus; helps hold humeral head in glenoid cavity |
Tibialis anterior |
Lower Leg/Ankle/Foot |
O: Lateral condyle and superior half lateral tibia
I: Base 1st metatarsal, plantar surface medial cuneiform |
Dorsiflexion ankle, foot inversion at subtalar and midtarsal joints |
Tibialis posterior |
Lower Leg/Ankle/Foot |
O: Interosseus membrane; posterior surface of tibia and fibula
I: Tuberosity of tarsal navicula, cuneiform and cuboid and bases of 2nd, 3rd and 4th metatarsals |
Plantar flexes ankle; inverts foot |
Triceps |
Shoulder/Upper Arm |
Long head:
O: Infraglenoid tubercle of scapula;
Lateral head:
O: Upper half of posterior surface shaft of humerus
Medial head
O: Lower half of posterior surface shaft of humerus
I: Olecranon process
Only muscle on the back of the arm |
Extends elbow joint; long head can adduct humerus and extend it from flexed position; stabilizes shoulder joint |
Except for nontraumatic tears of the rotator cuff which are captured in subcategory M75.1, codes for nontraumatic tendon tears are found in subcategories M66.2-M66.8 and are defined as spontaneous rupture.
Coding and Documentation Requirements
Identify rupture as not related to injury or trauma.
Identify site of nontraumatic tendon rupture:
•Upper extremity
–Shoulder
–Upper arm
–Forearm
–Hand
•Lower extremity
–Thigh
–Lower leg
–Ankle/foot
•Other site
•Multiple sites
•Unspecified tendon
Identify action of tendon:
•Extensor
•Flexor
•Other
ICD-10-CM Code/Documentation |
M66.221 |
Spontaneous rupture of extensor tendons, right upper arm |
M66.222 |
Spontaneous rupture of extensor tendons, left upper arm |
M66.229 |
Spontaneous rupture of extensor tendons, unspecified upper arm |
M66.311 |
Spontaneous rupture of flexor tendons, right shoulder |
M66.312 |
Spontaneous rupture of flexor tendons, left shoulder |
M66.319 |
Spontaneous rupture of flexor tendons, unspecified shoulder |
M66.321 |
Spontaneous rupture of flexor tendons, right upper arm |
M66.322 |
Spontaneous rupture of flexor tendons, left upper arm |
M66.329 |
Spontaneous rupture of flexor tendons, left upper arm |
M66.231 |
Spontaneous rupture of extensor tendons, right forearm |
M66.232 |
Spontaneous rupture of extensor tendons, left forearm |
M66.239 |
Spontaneous rupture of extensor tendons, unspecified forearm |
M66.241 |
Spontaneous rupture of extensor tendons, right hand |
M66.242 |
Spontaneous rupture of extensor tendons, left hand |
M22.249 |
Spontaneous rupture of extensor tendons, unspecified hand |
M66.331 |
Spontaneous rupture of flexor tendons, right forearm |
M66.332 |
Spontaneous rupture of flexor tendons, left forearm |
M66.339 |
Spontaneous rupture of flexor tendons, unspecified forearm |
M66.341 |
Spontaneous rupture of flexor tendons, right hand |
M66.342 |
Spontaneous rupture of flexor tendons, left hand |
M66.349 |
Spontaneous rupture of flexor tendons, unspecified hand |
M66.251 |
Spontaneous rupture of extensor tendons, right thigh |
M66.252 |
Spontaneous rupture of extensor tendons, left thigh |
M66.259 |
Spontaneous rupture of extensor tendons, unspecified thigh |
M66.261 |
Spontaneous rupture of extensor tendons, right lower leg |
M66.262 |
Spontaneous rupture of extensor tendons, left lower leg |
M66.269 |
Spontaneous rupture of extensor tendons, unspecified lower leg |
M66.361 |
Spontaneous rupture flexor tendons, right lower leg |
M66.362 |
Spontaneous rupture flexor tendons, left lower leg |
M66.369 |
Spontaneous rupture flexor tendons, unspecified lower leg |
M66.271 |
Spontaneous rupture of extensor tendons, right ankle and foot |
M66.272 |
Spontaneous rupture of extensor tendons, left ankle and foot |
M66.279 |
Spontaneous rupture of extensor tendons, unspecified ankle and foot |
M66.371 |
Spontaneous rupture of flexor tendons, right ankle and foot |
M66.372 |
Spontaneous rupture of flexor tendons, left ankle and foot |
M66.379 |
Spontaneous rupture of flexor tendons, unspecified ankle and foot |
M66.28 |
Spontaneous rupture of extensor tendons, other site |
M66.29 |
Spontaneous rupture of extensor tendons, multiple sites |
M66.351 |
Spontaneous rupture of flexor tendons, right thigh |
M66.352 |
Spontaneous rupture of flexor tendons, left thigh |
M66.359 |
Spontaneous rupture of flexor tendons, unspecified thigh |
M66.38 |
Spontaneous rupture of flexor tendons, other site |
M66.39 |
Spontaneous rupture of flexor tendons, multiple sites |
Documentation and Coding Example
Eighty-one-year-old Caucasian female is brought into ED by EMS after she awoke this morning with bilateral ankle swelling and pain that prevented her from getting out of bed. Patient resides alone and is able to drive and care completely for herself. She was in her usual state of good health until approximately two weeks ago when she became acutely ill with fever, malaise, and cough. She is fastidious about obtaining an annual flu vaccine so she attributed her symptoms to a summer cold. When her cough became productive and was accompanied by wheezing, she visited her PMD who obtained a CXR which showed left lower lobe infiltrates and was subsequently prescribed Advair Inhaler BID, Levaquin 500 mg BID, and albuterol inhaler prn. She has been on these medications for 6 days and is just beginning to have some energy. She saw her PMD yesterday and a repeat CXR showed improvement. She noticed some stiffness in her right ankle last evening and dismissed it as simply muscle disuse but was dismayed this morning when both ankles were swollen and painful and she was unable to walk. She called her daughter who came right over and PMD advised transfer to ED by EMS. On examination, this is an anxious but pleasant octogenarian who looks younger than her stated age. She is alert and oriented x 3 and an excellent historian. T 96.1, P 80, R 18, BP 114/84 O2 Sat on RA is 96%. She states she is widowed x 20 years. Her husband was in the diplomatic service and they traveled extensively. After his death she become somewhat of a celebrity by authoring a series of books on cooking and culinary adventure. Travel immunizations are current and her last trip was 3 months ago to Belize. She swims and/or walks daily and has had no recent injuries that she can recall. Heart rate shows SR on monitor with occasional benign PVCs. No audible murmur, bruit, or rubs are appreciated. Breath sounds have scattered wheezes with slightly decreased sounds in the left base. Abdomen soft, non-distended. Cranial nerves grossly intact and upper extremities WNL. Hips and knees are without swelling or pain and ROM is intact. There is a moderate amount of circumferential swelling in each ankle. No redness, bruising, or discoloration noted. Unable to adequately palpate along the Achilles tendon due to swelling and discomfort but a gap may be present 3-4 cm above heel on the right. Neurovascular status of feet and toes is unremarkable. Passive ROM to ankles elicits considerable pain and she is unable to actively plantar flex. Thompson’s sign is positive as is Homan’s. Given her recent illness and immobility, venous Doppler study is performed and DVT is ruled out. MRI of bilateral ankles was obtained which is significant for Achilles rupture 4.5 cm proximal to calcaneal insertion site on the right and 6 cm proximal on the left. There is no evidence of pre-existing tendinopathy in either extremity.
Impression: Non-traumatic bilateral Achilles tendon rupture possibly due to fluoroquinolone and steroid use.
Plan: Discontinue Levaquin and Advair and admit to orthopedic service.
Diagnosis Code(s)
M66.361 |
Spontaneous rupture flexor tendons right lower leg |
M66.362 |
Spontaneous rupture flexor tendons left lower leg |
Coding Note(s)
Nontraumatic ruptures of the tendon are defined by their action, not the specific tendon. The Achilles tendon is a flexor tendon in the lower leg. Laterality is a component of the code and so separate codes for right and left are reported since there is not a bilateral code. The documentation states that the tendon ruptures are “possibly” due to the fluoroquinolone and steroid use. Because the qualifier “possibly” is used, this would not be coded as an adverse effect for the ED encounter; however, it may be appropriate to code the adverse effect if the discharge summary also lists these medications as the cause or possible cause of the tendon ruptures.
Scoliosis
Scoliosis is an abnormal sideways curvature in the spine. The condition may be congenital (present at birth) or develop later in life, usually around the time of puberty. Congenital scoliosis is usually caused by vertebral anomalies. Other causes can include neuromuscular disorders (cerebral palsy, spinal muscular atrophy), trauma, and certain syndromes (Marfan’s, Prader-Willi). In the majority of cases, no cause can be found and the condition is termed idiopathic. Scoliosis can decrease lung capacity, place pressure on the heart and large blood vessels in the chest, and may restrict physical activity.
Codes for scoliosis are listed in category M41. Codes are classified as idiopathic, thoracogenic, neuromuscular, other secondary scoliosis, other forms of scoliosis, and unspecified scoliosis. Codes for idiopathic scoliosis are categorized
based on age at diagnosis as infantile (from birth through age 4), juvenile (ages 5 through 9 years), and adolescent (ages 11 through 17 years). There is also a subcategory for other idiopathic scoliosis. In addition, the site of curvature must be documented as cervical, cervicothoracic, thoracic, thoracolumbar, lumbar, or lumbosacral. These codes are not reported for congenital scoliosis which is reported with a code from
Chapter 17 Congenital Malformations, Deformations, and Chromosomal Abnormalities.
Coding and Documentation Requirements
Identify type of scoliosis:
•Idiopathic
–Infantile
–Juvenile
–Adolescent
–Other
•Secondary
–Neuromuscular
–Other
•Thoracogenic
•Other form
•Unspecified
Identify site:
•Cervical
•Cervicothoracic
•Thoracic
•Thoracolumbar
•Lumbar
•Lumbosacral
•Sacral/sacrococcygeal (only applies to infantile idiopathic scoliosis)
•Site unspecified
Idiopathic Scoliosis
ICD-10-CM Code/Documentation |
Juvenile |
M41.112 |
Juvenile idiopathic scoliosis, cervical region |
M41.113 |
Juvenile idiopathic scoliosis, cervicothoracic region |
M41.114 |
Juvenile idiopathic scoliosis, thoracic region |
M41.115 |
Juvenile idiopathic scoliosis, thoracolumbar region |
M41.116 |
Juvenile idiopathic scoliosis, lumbar region |
M41.117 |
Juvenile idiopathic scoliosis, lumbosacral region |
M41.119 |
Juvenile idiopathic scoliosis, site unspecified |
Adolescent |
M41.122 |
Adolescent idiopathic scoliosis, cervical region |
M41.123 |
Adolescent idiopathic scoliosis, cervicothoracic region |
M41.124 |
Adolescent idiopathic scoliosis, thoracic region |
M41.125 |
Adolescent idiopathic scoliosis, thoracolumbar region |
M41.126 |
Adolescent idiopathic scoliosis, lumbar region |
M41.127 |
Adolescent idiopathic scoliosis, lumbosacral region |
M41.129 |
Adolescent idiopathic scoliosis, site unspecified |
Other |
M41.20 |
Other idiopathic scoliosis, site unspecified |
M41.22 |
Other idiopathic scoliosis, cervical region |
M41.23 |
Other idiopathic scoliosis, cervicothoracic region |
M41.24 |
Other idiopathic scoliosis, thoracic region |
M41.25 |
Other idiopathic scoliosis, thoracolumbar region |
M41.26 |
Other idiopathic scoliosis, lumbar region |
M41.27 |
Other idiopathic scoliosis, lumbosacral region |
Infantile |
M41.00 |
Infantile idiopathic scoliosis, site unspecified |
M41.02 |
Infantile idiopathic scoliosis, cervical region |
M41.03 |
Infantile idiopathic scoliosis, cervicothoracic region |
M41.04 |
Infantile idiopathic scoliosis, thoracic region |
M41.05 |
Infantile idiopathic scoliosis, thoracolumbar region |
M41.06 |
Infantile idiopathic scoliosis, lumbar region |
M41.07 |
Infantile idiopathic scoliosis, lumbosacral region |
M41.08 |
Infantile idiopathic scoliosis, sacral and sacrococcygeal region |
Documentation and Coding Example
Twelve-year-old Hispanic female is referred to Pediatric Orthopedic Clinic by PMD for suspected scoliosis. She was initially noted to have a right thoracic curve of 7 degrees during routine screening by her school nurse. Patient was subsequently seen by her pediatrician who examined her and obtained x-rays that indeed supported the school screening results. PMH is significant for allergies and asthma well controlled with Singulair 5 mg daily, Xopenex inhaler only occasionally for symptoms. She also uses topical hydrocortisone for eczema PRN. On examination, this is a thin but well-nourished adolescent female, developmentally a Tanner II-III. Upper and lower reflexes intact, abdominal reflex pattern normal. Right shoulder is rotated forward and medial border of right scapula protrudes posteriorly. Examination of lower extremities shows negative hamstring tightness and a 1 cm length discrepancy. No ataxia and negative Romberg. Radiographs viewed on computer with parent and patient and are significant for a 30 degree right thoracic curve. Diagnosis and treatment options discussed and questions answered. Patient will be fitted with a brace to be worn 16 hours a day. RTC in 3 months for repeat x-rays and examination.
Diagnosis Code(s)
M41.124 |
Adolescent idiopathic scoliosis, thoracic region |
Coding Note(s)
In order to assign the most specific code for idiopathic scoliosis, the age of the patient and the site of the curvature must be documented.
Spondylosis
Spondylosis is stiffening or fixation of the vertebral joint(s) with fibrous or bony union across the joint resulting from age or a disease process. Spondylosis affects the vertebrae, intervertebral disc, and soft tissues of the spine. The condition may be complicated by spinal cord dysfunction, also referred to as myelopathy, resulting from narrowing of the spinal column and compression of the spinal cord. Spondylosis may also cause radiculopathy which is a general term for pain resulting from compression of a nerve. There are a number of very similar terms for conditions affecting the spine. Do not confuse spondylosis with spondylosis which is a degenerative or developmental deficiency of a portion of the vertebra, commonly involving the pars interarticularis. Careful review of the documentation is required to ensure that the correct code is assigned.
Category M47 contains codes for spondylosis. This category includes conditions documented as arthrosis or osteoarthritis of the spine and degeneration of the facet joints. There are subcategories for anterior spinal artery compression syndromes (M47.01) and vertebral artery compression syndromes (M47.02). Combination codes exist for spondylosis with myelopathy (M47.1-) and with radiculopathy (M47.2-). Spondylosis without myelopathy or radiculopathy is reported with codes from subcategory (M47.81-). There is also a subcategory for other specified spondylosis (M47.89) and a single code for spondylosis unspecified (M47.9). Codes are specific to the following regions of the spine: occipito-atlanto-axial (occiput to 2nd cervical), cervical, cervicothoracic (6th cervical to 1st thoracic), thoracic, thoracolumbar (10th thoracic to 1st lumbar), lumbar, lumbosacral (5 lumbar and 5 sacral), and sacral/sacrococcygeal.
Coding and Documentation Requirements
Identify condition:
•Anterior spinal artery compression syndrome
•Vertebral artery compression syndrome
•Spondylosis
–with myelopathy
–with radiculopathy
–without myelopathy or radiculopathy
–Other specified type
–Unspecified
Identify site:
•Occipito-atlanto-axial region
•Cervical region
•Cervicothoracic region
•Thoracic region
•Thoracolumbar region
•Lumbar region
•Lumbosacral region
•Sacral/sacrococcygeal region
•Unspecified site
ICD-10-CM Code/Documentation |
M47.016 |
Anterior spinal artery compression syndromes, lumbar region |
M47.26 |
Other spondylosis with radiculopathy, lumbar region |
M47.27 |
Other spondylosis with radiculopathy, lumbosacral region |
M47.28 |
Other spondylosis with radiculopathy, sacral and sacrococcygeal region |
M47.816 |
Spondylosis without myelopathy or radiculopathy, lumbar region |
M47.817 |
Spondylosis without myelopathy or radiculopathy, lumbosacral region |
M47.818 |
Spondylosis without myelopathy or radiculopathy, sacral and sacrococcygeal region |
M47.896 |
Other spondylosis, lumbar region |
M47.897 |
Other spondylosis, lumbosacral region |
M47.898 |
Other spondylosis, sacral and sacrococcygeal region |
M47.16 |
Other spondylosis with myelopathy, lumbar region |
Documentation and Coding Example
Fifty-eight-year-old Caucasian male presents to Occupational Medicine for routine physical. Patient is a long-distance truck driver x 20 years. His only complaints are more frequent need to urinate and some mild low back pain and paresthesia in his left thigh. T 98.8, P 78, R 14, BP 138/88, Ht. 70 inches, Wt. 155 lbs. Vision is 20/30 with glasses. Hearing by audiometry is WNL. EKG shows NSR without ectopy. On examination PERRL, neck supple without lymphadenopathy. Nares patent, oral mucosa, pharynx moist and pink. Cranial nerves grossly intact. Neuromuscular exam of upper extremities unremarkable. Heart rate regular without bruit, rub, murmur. Breath sounds clear, equal bilaterally. Spinal column straight with mild tenderness in lumbar/sacral area. Abdomen soft, active bowel sounds. No evidence of hernia, testicles smooth. Circumcised penis is without discharge. Good sphincter tone on rectal exam, smooth, slightly enlarged prostate. Good ROM in lower extremities. Gait normal. Reflexes intact. Leg lifts do not produce pain. Sensation, both dull and sharp is reduced from lateral aspect to midline anterior of left thigh starting 4 cm below the hip ending 2 cm above the knee. He describes a prickling or tingling sensation at times over that entire area. Radiographs of spine obtained and reveal bony overgrowth on vertebral bodies L1-L4 and mild narrowing of the disc space. No disc protrusion is seen.
Impression: Lumbar spondylosis with radiculopathy involving L1-L4.
Plan: Occupational/Physical therapy evaluation and 12 treatments authorized. Risk management to evaluate his truck drivers seat for possible modifications after he is seen by OT/PT and recommendations are made. RTC in 4 weeks, sooner if symptoms worsen.
Diagnosis Code(s)
M47.26 |
Other spondylosis with radiculopathy, lumbar region |
Coding Note(s)
There is a combination code that captures spondylosis, which is the disease process, and radiculopathy which is a common symptom of spondylosis.
Stress Fracture
A stress fracture is a small crack or break in a bone that arises from unusual or repeated force or overuse in an area of the body, most commonly the lower legs and feet. Symptoms include generalized pain and tenderness. When a stress fracture occurs in the lower extremity, pain and tenderness may increase with weight bearing. The pain may also be more pronounced at the beginning of exercise, decrease during the activity, and then increase again at the end of the workout.
There are specific codes for stress fractures of the pelvis and extremities as well as for stress fractures of the vertebrae. Stress fractures of the vertebrae are referred to as fatigue fractures with the alternate term stress fracture also listed. Fatigue fractures of the vertebrae are located in subcategory M48.4 and codes are specific to the region of the spine. There is also a subcategory (M48.5) for collapsed vertebra which may also be documented as wedging of vertebra. Codes for collapsed vertebra are not used to report fatigue fractures, pathological fractures due to neoplasm, osteoporosis or other pathological condition, or for traumatic fractures. Codes for stress fractures of other sites are located in subcategory M84.3 and codes are specific to site and also require documentation of laterality.
Coding and Documentation Requirements
For stress fracture of pelvis/extremity identify:
•Site
–Lower extremity
»Femur
»Tibia
»Fibula
»Ankle
»Foot
»Toe(s)
–Pelvis
–Upper extremity
»Shoulder
»Humerus
»Radius
»Ulna
»Hand
»Finger(s)
•Laterality (not required for pelvis)
–Right
–Left
–Unspecified
•Episode of care
–Initial encounter
–Subsequent encounter
»With routine healing
»With delayed healing
»With nonunion
»With malunion
–Sequela
For fatigue fracture/collapsed vertebra, identify:
•Type
–Fatigue fracture
–Collapsed vertebra (wedging)
•Site/region of spine
–Occipito-atlanto-axial region
–Cervical
–Cervicothoracic
–Thoracic
–Thoracolumbar
–Lumbar
–Lumbosacral
–Sacral/sacrococcygeal
–Unspecified site
•Episode of care
–Initial encounter
–Subsequent encounter
»With routine healing
»With delayed healing
–Sequela
Stress Fracture Ankle/Foot/Toes
ICD-10-CM Code/Documentation |
M84.371- |
Stress fracture, right ankle |
M84.372- |
Stress fracture, left ankle |
M84.373- |
Stress fracture, unspecified ankle |
M84.374- |
Stress fracture, right foot |
M84.375- |
Stress fracture, left foot |
M84.376- |
Stress fracture, unspecified foot |
M84.377- |
Stress fracture, right toe(s) |
M84.378- |
Stress fracture, left toe(s) |
M84.379- |
Stress fracture, unspecified toe(s) |
Documentation and Coding Example
Patient is a twenty-eight-year-old Asian female who presents to Physiatrist with c/o right foot pain. She is well known to this practice as a member of a professional ballet company that we consult for. This petite, well nourished, graceful young woman is 3 months postdelivery of her first child. She retired from performing 2 years ago but has been teaching in the ballet school. She remained active during her pregnancy by taking ballet, Pilates, or yoga classes almost daily. She returned to teaching 2 months ago, usually assigned to upper level students 4 days a week. She noticed right mid-foot pain that radiated along the medial longitudinal arch one week after she returned to teaching. The pain increases with exercise and usually goes away with rest. For the past week she has noticed her shoes feel tight over that area but she has not noticed bruising or obvious swelling. On examination, there is mild dorsal foot swelling, pain with passive eversion and active inversion. Point tenderness is present at the mid medial arch and proximal to the dorsal portion of the navicular bone. X-ray obtained using a coned-down AP radiograph centered on the tarsal navicular which reveals a small lateral fragment of the tarsal navicular bone.
Impression: Stress fracture of the right navicular.
Plan: Walking boot x 6 weeks. Patient is advised to do non-weight bearing exercise only. RTC in 6 weeks for repeat x-ray and referral to PT.
Diagnosis Code(s)
M84.374A |
Stress fracture, right foot, initial encounter |
Coding Note(s)
The tarsal navicular bone is one of the 7 tarsal bones of the foot. Under Fracture, traumatic, stress, tarsus in the Alphabetic Index, code M84.374- is identified as the correct code.
Summary
For the majority of connective tissue conditions and diseases of the musculoskeletal system specific documentation is required related to anatomic site and laterality. Episode of care is required for nontraumatic fractures (stress, pathologic and fractures related to osteoporosis). In addition, the need to clearly differentiate acute traumatic conditions from old or chronic conditions must be specified.
Resources
Documentation checklists are available in
Appendix A for the following conditions:
•Gout
•Rheumatoid arthritis
Chapter 15 Quiz
1.What condition below does not require documentation of episode of care?
a.Collapsed vertebra
b.Fatigue fracture of vertebra
c.Unspecified disorder of bone continuity
d.Stress fracture of foot
2.The ED physician has documented that an 82-year-old patient with severe senile osteoporosis sustained a left hip fracture from a same level fall on a carpeted surface. What code is reported for the fracture?
a.M80.052A Age-related osteoporosis with current pathological fracture, left femur, initial encounter
b.M80.852A Other osteoporosis with current pathological fracture, left femur, initial visit
c.S72.002A Fracture of unspecified part of neck of left femur, initial encounter for closed fracture
d.S72.065A Nondisplaced articular fracture of head of left femur, initial encounter for closed fracture
3.Identify which condition affecting the musculoskeletal system would generally not be reported with a code from
Chapter 13.
a.Healed injury
b.Recurrent bone, joint or muscle condition
c.Chronic conditions
d.Current acute injury
4.The physician has documented that the patient has idiopathic osteonecrosis of the right femoral head. Since this condition affects the joint, what site is reported?
a.The site is the joint
b.The site is the bone
c.The site is a combination code for the joint and the bone
d.Two sites are reported identifying the bone and the joint
5.What condition is not reported with a code from
Chapter 13?
a.Arthropathic psoriasis
b.Drug-induced gout
c.Adhesive capsulitis of the shoulder
d.Nontraumatic compartment syndrome
6.What condition would be reported with a code from subcategory M48.5- Collapsed vertebra?
a.Current injury due to fatigue fracture
b.New pathological fracture of vertebra due to neoplasm
c.Wedging of vertebra
d.Traumatic vertebral fracture
7.What information is NOT required to assign the most specific code for idiopathic scoliosis?
a.Age of the patient at onset of the condition
b.Location of the curve
c.Affected region of the spine
d.The specific form of scoliosis
8.Codes for osteoporosis in category M80 are specific to site. What does the site designate?
a.The site of the osteoporosis and fracture
b.The site of the osteoporosis
c.The site of the fracture
d.None of the above
9.Code M61.371 Calcification and ossification of muscles associated with burns, right ankle and foot is an example of what type of code?
a.An injury code
b.A combination code
c.An episode of care code
d.None of the above
10.What descriptor is not an example of site specificity?
a.Mid-cervical region
b.Achilles tendon
c.Synovium
d.First carpometacarpal joints
11.What information must be documented to assign the most specific code in category M1A Chronic gout that is not required for codes in category M10 Gout?
a.With or without tophus
b.Site
c.Laterality
d.All of the above
Chapter 15 Answers and Rationales
1.What condition does not require documentation of episode of care?
c.Unspecified disorder of bone continuity
Rationale: Collapsed vertebra (M48.5-), fatigue fracture of vertebra (M48.4), and stress fracture of foot (M84.37-) all require documentation of episode of care. Unspecified disorder of bone continuity, even though it is also classified in category M84, does not require documentation episode of care.
2.The ED physician has documented that an 82-year-old patient with severe senile osteoporosis sustained a left hip fracture when he sustained a same level fall on a carpeted surface. What code is reported for the fracture?
a.M80.052A Age-related osteoporosis with current pathological fracture, left femur, initial encounter
Rationale: A code from category M80, not a traumatic fracture code, should be used for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal, healthy bone. The physician has documented that the patient has senile osteoporosis which is a reported with the code for age-related osteoporosis.
3.Identify which condition affecting the musculoskeletal system would generally not be reported with a code from
Chapter 13.
d.Current acute injury
Rationale: Chapter guidelines identify healed, recurrent injuries and chronic conditions affecting the musculoskeletal system as conditions that are usually reported with codes from Chapter 13. Current acute injuries are usually reported with codes from Chapter 19.
4.The physician has documented that the patient has idiopathic osteonecrosis of the right femoral head. Since this condition affects the joint, what site is reported?
b.The site is the bone
Rationale: Coding guidelines related to site state the following: 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.
5.What condition is not reported with a code from
Chapter 13?
a.Arthropathic psoriasis
Rationale: The chapter level Excludes2 note identifies arthropathic psoriasis (L40.5-) as a condition that is not reported with a code from Chapter 13.
6.What condition would be reported with a code from subcategory M48.5- Collapsed vertebra?
c.Wedging of vertebra
Rationale: Subcategory (M48.5) is reported for collapsed vertebra, which may also be documented as wedging of vertebra. Codes for collapsed vertebra are not used to report a current injury due to fatigue fracture, pathological fractures due to neoplasm, osteoporosis or other pathological condition, or for traumatic fractures.
7.What information is NOT required to assign the most specific code for idiopathic scoliosis?
d.The specific form of scoliosis
Rationale: Idiopathic scoliosis is a specific form of scoliosis. It identifies the condition as being of unknown cause. Other forms are thoracogenic, neuromuscular, other secondary and other specified forms. The age of the patient is required in order to correctly classify the condition as infantile, juvenile, or adolescent. The location of the curve must be identified which may be documented as involving the either by the vertebra (T5-T10) involved or the region of the spine (thoracic).
8.Codes for osteoporosis in category M80 are specific to site. What does the site designate?
c.The site of the fracture
Rationale: Osteoporosis is a systemic condition, meaning that all bones of the musculoskeletal system are affected. Therefore, site is not a component of the codes under category M81 Osteoporosis without current pathological fracture. The site codes under M80 Osteoporosis with current pathological fracture identify the site of the fracture not the osteoporosis.
9.Code M61.371 Calcification and ossification of muscles associated with burns, right ankle and foot is an example of what type of code?
b.A combination code
Rationale: This is an example of a combination code. It captures the disease, disorder or other condition which is calcification and ossification of the muscles and the cause or etiology of the condition which is the burn.
10.What descriptor is not an example of site specificity?
c.Synovium
Rationale: Synovium is a type of tissue in the joints not a specific site in the musculoskeletal system. The site would be a specific joint such as the shoulder, wrist, or knee.
11.What information must be documented to assign the most specific code in category M1A Chronic gout that is not required for codes in category M10 Gout?
a.With or without tophus
Rationale: A 7th character is required for chronic gout to identify the condition as with or without tophus.