Diseases of the Musculoskeletal System and Connective Tissue M51 – M99 (Part 2)
Presented by David Freedman, DPM, CPC, CSFAC, CPMA Webinar 5b: Thursday, April 3, 2014
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7 APMA Coding Resource Center
8 ICD-10-CM Rules M51-M99 MSK Part 2
Chapter 13: Diseases of the musculoskeletal system and connective tissue (M00-M99)
Note: Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition.
9 Tonight we continue with M77 and finish the MSK
10 ICD-10 Review of some Rules
“SYMBOLS and CONVENTIONS Reviewed”
1) The “Excludes 1” is when two conditions can not occur together.
2) The “Excludes 2” means not included here. This is the case where it is acceptable to use both the code and the excluded code together.
3) The “Code first/Use additional code” means when there are multiple body system manifestations you code the underlying condition first and the manifestation second.
11 Chief Complaint: Doc there is pain you know right here, directly under the ball of the right foot in the middle, you know.
12 Musculoskeletal: Inspection and palpation reveals the right foot exhibits generalized pain to the ball of the foot but no pain was noted in the interspace along the nerve.
Impression: Metatarsalgia, right foot.
13 Go to Index first
Metatarsalgia M77.4- - anterior G57.6- - Morton's G57.6-
14 Go to the Tabular
M77.4 Metatarsalgia Excludes1: Morton's metatarsalgia (G57.6) M77.40 Metatarsalgia, unspecified foot M77.41 Metatarsalgia, right foot M77.42 Metatarsalgia, left foot
15 ICD 9 ICD 10 M77.41 Metatarsalgia, 726.70 Metatarsalgia right foot
16 Chief Complaint: Doc there is burning and tingling in front of the left ankle and along the outside of the ankle and foot too.
17 Musculoskeletal: Inspection and palpation reveals the left ankle and foot exhibits no MSK deformities.
Neurological: There inflammation noted along the Intermediate dorsal cutaneous nerve and the Sural nerve along the left foot and ankle.
Impression: Neuritis, left ankle and foot
18 Go to Index first
Neuralgia, neuralgic (acute) M79.2 Neuritis (rheumatoid) M79.2
19 Go to the Tabular
M79.2 Neuralgia and neuritis, unspecified
Excludes1: brachial radiculitis NOS (M54.1) lumbosacral radiculitis NOS (M54.1) mononeuropathies (G56-G58) radiculitis NOS (M54.1) sciatica (M54.3-M54.4)
20 ICD 9 ICD 10 729.2 Neuralgia and M79.2 Neuralgia and neuritis, unspecified neuritis, unspecified
21 Chief Complaint: “There is pain everywhere”. Today there is pain and tenderness in the legs, tops of the feet and the toes.
22 Musculoskeletal: Inspection and palpation reveals the left and right lower legs, ankles and feet exhibits generalized aches and pains anywhere this patient is examined.
Impression: Fibromyalgia left and right lower legs, ankles and feet
23 Go to Index first
Fibromyalgia M79.7
24 Go to the Tabular
M79.7 Fibromyalgia Fibromyositis Fibrositis Myofibrositis
25 ICD 9 ICD 10
729.1 Fibromyalgia M79.7 Fibromyalgia
26 Chief Complaint: There is pain in the front of the right ankle and top of the right foot.
27 Musculoskeletal: Inspection and palpation reveals a generalized right ankle and foot pain.
Impression: Pain in the right ankle and foot.
28 ICD 10 go to the Index
Pain - foot —see Pain, limb, lower
- limb M79.609 - - lower M79.60- - - - foot M79.67- - - - lower leg M79.66- - - - thigh M79.65- - - - toe M79.67-
29 ICD 10 Go to the Tabular M79.6 Pain in limb, hand, foot, fingers and toes Excludes2: pain in joint (M25.5-)
M79.60 Pain in limb, unspecified M79.604 Pain in right leg Pain in right lower limb NOS M79.605 Pain in left leg Pain in left lower limb NOS M79.606 Pain in leg, unspecified Pain in lower limb NOS M79.609 Pain in unspecified limb Pain in limb NOS Comment: At first this seems adequate but it is not to highest level of specificity, so we keep going
30 ICD 10 go to the Tabular
M79.66 Pain in lower leg M79.661 Pain in right lower leg M79.662 Pain in left lower leg M79.669 Pain in unspecified lower leg
(*Comment: Pain in right ankle is included in lower leg*)
31 Go to the Tabular M79.67 Pain in foot and toes 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 toe(s) M79.676 Pain in unspecified toe(s)
32 ICD 9 ICD 10 M79.661 Pain in right 729.5 Pain lower leg M79.671 Pain in right 729.5 Pain foot
33 Chief Complaint: A 90 year old female presents today relating “there is pain in the right foot that just started to be painful after walking the family dog this past weekend with my family in their neighborhood”.
34 Musculoskeletal: Inspection and palpation reveals localized pain to the right foot 2nd metatarsal.
Radiologic Examination: AP, Lateral and Medial Oblique views reveals an oblique fracture of the 2nd metatarsal, there is spotty diffuse loss of bone density throughout all the metatarsals.
Impression: Osteoporosis with a 2nd metatarsal fracture in the right foot
35 ICD 10 go to the Index
Fracture, pathological (pathologic) —see also Fracture, traumatic M84.40 - ankle M84.47- - fibula M84.46- - metatarsus M84.47- - tarsus M84.47- - tibia M84.46- - toe M84.47- - - osteoporosis M80.80
36 ICD 10 go to the Index
Osteoporosis (female) (male) M81.0 - with current pathological fracture M80.00 - - - fibula M80.06- - - - metatarsus M80.07– - - - tarsus M80.07- - - - tibia M80.06- - - - toe M80.07-
37 ICD 10 go to the Tabular
M80 Osteoporosis with current pathological fracture
Includes: Osteoporosis with current fragility fracture Use additional code to identify major osseous defect, if applicable (M89.7-)
Excludes1: collapsed vertebra NOS (M48.5) pathological fracture NOS (M84.4) wedging of vertebra NOS (M48.5)
38 M80 Osteoporosis with current pathological fracture - Cont’d Excludes2: personal history of (healed) osteoporosis fracture (Z87.310) The appropriate 7th character is to be added to each code from category M80: A - initial encounter for fracture D - subsequent encounter for fracture with routine healing G - subsequent encounter for fracture with delayed healing K - subsequent encounter for fracture with nonunion P - subsequent encounter for fracture with malunion S - sequela
39 Go to the Tabular
M80.07 Age-related osteoporosis with current pathological fracture, ankle and foot M80.071 Age-related osteoporosis with current pathological fracture, right ankle and foot M80.072 Age-related osteoporosis with current pathological fracture, left ankle and foot M80.079 Age-related osteoporosis with current pathological fracture, unspecified ankle and foot
40 Go Back to the Tabular and find Activity
Y93.0 Activities involving walking and running Excludes1: activity, walking an animal (Y93.K1) activity, walking or running on a treadmill (Y93.A1)
Y93.01 Activity, walking, marching and hiking Activity, walking, marching and hiking on level or elevated terrain Excludes1: activity, mountain climbing (Y93.31)
41 But must continue in the Tabular and find her specific activity
Y93.K Activities involving animal care Excludes1: activity, horseback riding (Y93.52) Y93.K1 Activity, walking an animal Y93.K2 Activity, milking an animal Y93.K3 Activity, grooming and shearing an animal Y93.K9 Activity, other involving animal care
42 ICD 9 ICD 10
825.25 Fracture M80.071A Age-related Metatarsal osteoporosis with current 733.01 Osteoporosis pathological fracture, (postmenopausal) right ankle and foot, initial encounter Y93.K1 Activity, walking No code an animal
43 So, what if this patient only had Osteoporosis and no fracture that is coded?
44 ICD 10 go to the Index
Osteoporosis (female) (male) M81.0 - with current pathological fracture M80.00 - - - fibula M80.06- - - - metatarsus M80.07– - - - tarsus M80.07- - - - tibia M80.06- - - - toe M80.07-
45 ICD 10 go to the Tabular-Rules
M81 Osteoporosis without current pathological fracture Use additional code to identify: major osseous defect, if applicable (M89.7-) personal history of (healed) osteoporosis fracture, if applicable (Z87.310) Excludes1: osteoporosis with current pathological fracture (M80.-) Sudeck's atrophy (M89.0)
46 Go to the Tabular
M81.0 Age-related osteoporosis without current pathological fracture Involutional osteoporosis without current pathological fracture Osteoporosis NOS Postmenopausal osteoporosis without current pathological fracture Senile osteoporosis without current pathological fracture
47 ICD 9 ICD 10 M81.0 Age-related 733.01 Osteoporosis osteoporosis without (postmenopausal) current pathological fracture
48 Chief Complaint: A high school male athlete relates training for cross country this past week ever afternoon, after school, he said he developed right shin pain about 5 miles into the run yesterday and it hurts.
49 Musculoskeletal: Inspection and palpation reveals localized pain to the right anterior tibia.
Radiologic Examination: AP, Lateral and Medial Oblique views reveals a possible oblique fracture of the right lower leg revealed no bony abnormality. The x-rays are not definitive.
MRI: Revealed bone marrow changes in the anterior tibia suggesting stress injury.
Impression: Stress Fracture of the right tibia
50 ICD 10 go to the Index
Fracture - stress M84.30 - - ankle M84.37- - - fibula M84.36- - - metatarsus M84.37- - - tarsus M84.37- - - tibia M84.36-
51 ICD 10 go to the Tabular-Rules
M84.3 Stress fracture Fatigue fracture March fracture Stress fracture NOS Stress reaction Use additional external cause code(s) to identify the cause of the stress fracture Excludes1: pathological fracture NOS (M84.4.-) pathological fracture due to osteoporosis (M80.-) traumatic fracture (S12.-, S22.-, S32.-, S42.-, S52.-, S62.-, S72.-, S82.-, S92.-)
52 ICD 10 go to the Tabular-Rules
M84.3 Stress fracture - continued Excludes2: personal history of (healed) stress (fatigue) fracture (Z87.312) stress fracture of vertebra (M48.4-) The appropriate 7th character is to be added to each code from subcategory M84.3: A - initial encounter for fracture D - subsequent encounter for fracture with routine healing G - subsequent encounter for fracture with delayed healing K - subsequent encounter for fracture with nonunion P - subsequent encounter for fracture with malunion S - sequela
53 Go to the Tabular
M84.36 Stress fracture, tibia and fibula M84.361 Stress fracture, right tibia M84.362 Stress fracture, left tibia M84.363 Stress fracture, right fibula M84.364 Stress fracture, left fibula M84.369 Stress fracture, unspecified tibia and fibula
54 ICD 9 ICD 10 M84.361A Stress 733.94 Stress fracture, fracture, right tibia, initial other encounter
55 Go back to the Tabular and obtain the external cause code, in this example the cause was running
56 Y93.0 Activities involving walking and running Excludes1: activity, walking an animal (Y93.K1) activity, walking or running on a treadmill (Y93.A1)
Y93.01 Activity, walking, marching and hiking Activity, walking, marching and hiking on level or elevated terrain Excludes1: activity, mountain climbing (Y93.31)
Y93.02 Activity, running
57 ICD 9 ICD 10
No code Y93.02 Activity, running
58 Putting it all together:
ICD 9 ICD 10
733.94 Stress M84.361A Stress fracture, fracture, other right tibia, initial encounter
No Code Y93.02 Activity, running
59 Chief Complaint: The daughter is here relating her mom had this red area around the outside of the right ankle. It was related that it seemed to get red and swollen then black just over the weekend.
60 Musculoskeletal: Inspection and palpation reveal the right ankle primarily along the fibula is erythematous, it has increased temperature with localized pain. There is an ulcer that probes to bone.
Radiologic examination: AP, Lateral and Oblique views reveal destructive changes to the right fibula, the lateral malleolus.
MRI: Revealed bone marrow edema changes in the right lateral malleolus and lysis of the cortex .
Impression: Osteomyelitis lateral malleolus, right fibula
61 ICD 10 go to the Index
Osteomyelitis (general) (infective) (localized) (neonatal) (purulent) (septic) (staphylococcal) (streptococcal) (suppurative)(with periostitis) M86.9 - acute M86.10 - - fibula M86.16- - - hematogenous M86.00 - - - fibula M86.06- - - - metatarsus M86.07- - - - multiple sites M86.09
62 ICD 10 go to the Tabular-Rules
M86 Osteomyelitis Use additional code (B95-B97) to identify infectious agent Use additional code to identify major osseous defect, if applicable (M89.7-) Excludes1: osteomyelitis due to: echinococcus (B67.2) gonococcus (A54.43) salmonella (A02.24)
63 ICD 10 go to the Tabular-Rules
M86 Osteomyelitis – continued Excludes2: ostemyelitis of: orbit (H05.0-) petrous bone (H70.2-) vertebra (M46.2-)
64 Go to the Tabular M86.06 Acute hematogenous osteomyelitis, tibia and fibula M86.061 Acute hematogenous osteomyelitis, right tibia and fibula M86.062 Acute hematogenous osteomyelitis, left tibia and fibula M86.069 Acute hematogenous osteomyelitis, unspecified tibia and fibula ***Can’t stop here***
65 Go to the Tabular
M86.07 Acute hematogenous osteomyelitis, ankle and foot M86.071 Acute hematogenous osteomyelitis, right ankle and foot M86.072 Acute hematogenous osteomyelitis, left ankle and foot M86.079 Acute hematogenous osteomyelitis, unspecified ankle and foot ***Can’t stop here***
66 Go to the Tabular
M86.16 Other acute osteomyelitis, tibia and fibula M86.161 Other acute osteomyelitis, right tibia and fibula M86.162 Other acute osteomyelitis, left tibia and fibula M86.169 Other acute osteomyelitis, unspecified tibia and fibula
67 Go to the Tabular
M86.17 Other acute osteomyelitis, ankle and foot M86.171 Other acute osteomyelitis, right ankle and foot M86.172 Other acute osteomyelitis, left ankle and foot M86.179 Other acute osteomyelitis, unspecified ankle and foot
68 ICD 9 ICD 10 730.07 Acute hematogenous Osteomyelitis osteomyelitis, ankle and foot (acute), ankle and M86.071 –Right foot M86.072 – Left Other acute osteomyelitis, ankle and foot M86.171 – Right M86.172 – Left
69 ICD 9 ICD 10 Acute hematogenous 730.06 osteomyelitis, right tibia and Osteomyelitis fibula (acute), lower leg M86.061 – Right M86.062 – Left Other acute osteomyelitis, right tibia and fibula M86.161 – Right M86.162 – Left
70 Can’t stop here if the infection was due to MRSA.
ICD 9 ICD 10 B95.62 Methicillin resistant 041.12 Methicillin- Staphylococcus aureus resistant staphylococcus infection as the cause of aureus (MRSA) diseases classified elsewhere (MRSA)
71 Chief Complaint: This patient was brought back in by their daughter relating her mom had the open sore re-open along the outside of the right ankle, that seemed to get red and swollen then black over the weekend.
HPI: This is the 4th time this has opened up and has drainage. She has been hospitalized 3 times for the bone infection and IV antibiotics
72 Musculoskeletal: Inspection and palpation reveals the right ankle along the fibula at the level of the malleolus has an erythematous, increased temperature with localized pain. There is recurrent ulcer that probes to bone and is draining.
Radiologic examination: AP, Lateral and Oblique views reveal destructive changes to the right fibular lateral malleolus.
Impression: Chronic Osteomyelitis lateral malleolus, right
73 ICD 10 go to the Index
Osteomyelitis (general) (infective) (localized) (neonatal) (purulent) (septic) (staphylococcal) (streptococcal) (suppurative)(with periostitis) M86.9 - chronic (or old) M86.60 - - with draining sinus M86.40 - - - fibula M86.46-
74 Go to the Tabular
M86.46 Chronic osteomyelitis with draining sinus, tibia and fibula
M86.461 Chronic osteomyelitis with draining sinus, right tibia and fibula M86.462 Chronic osteomyelitis with draining sinus, left tibia and fibula M86.469 Chronic osteomyelitis with draining sinus, unspecified tibia and fibula
75 Go to the Tabular
M86.47 Chronic osteomyelitis with draining sinus, ankle and foot
M86.471 Chronic osteomyelitis with draining sinus, right ankle and foot M86.472 Chronic osteomyelitis with draining sinus, left ankle and foot M86.479 Chronic osteomyelitis with draining sinus, unspecified ankle and foot
76 Go to the Tabular M86.56 Other chronic hematogenous osteomyelitis, tibia and fibula
M86.561 Other chronic hematogenous osteomyelitis, right tibia and fibula M86.562 Other chronic hematogenous osteomyelitis, left tibia and fibula M86.569 Other chronic hematogenous osteomyelitis, unspecified tibia and fibula
77 Go to the Tabular M86.57 Other chronic hematogenous osteomyelitis, ankle and foot
M86.571 Other chronic hematogenous osteomyelitis, right ankle and foot M86.572 Other chronic hematogenous osteomyelitis, left ankle and foot M86.579 Other chronic hematogenous osteomyelitis, unspecified ankle and foot
78 Go to the Tabular
M86.66 Other chronic osteomyelitis, tibia and fibula
M86.661 Other chronic osteomyelitis, right tibia and fibula M86.662 Other chronic osteomyelitis, left tibia and fibula M86.669 Other chronic osteomyelitis, unspecified tibia and fibula
79 Go to the Tabular
M86.67 Other chronic osteomyelitis, ankle and foot
M86.671 Other chronic osteomyelitis, right ankle and foot M86.672 Other chronic osteomyelitis, left ankle and foot M86.679 Other chronic osteomyelitis, unspecified ankle and foot
80 ICD 9 ICD 10
Chronic osteomyelitis with 730.16 draining sinus, tibia and fibula Osteomyelitis M86.461 – Right (chronic), lower leg M86.462 – Left
Chronic osteomyelitis with 730.17 Osteomyelitis draining sinus, ankle and foot (chronic), ankle and M86.471 – Right foot M86.472 – Left
81 ICD 9 ICD 10
Other chronic osteomyelitis, tibia 730.16 and fibula Osteomyelitis M86.661 – Right (chronic), lower leg M86.662 – Left
Other chronic osteomyelitis, ankle 730.17 Osteomyelitis and foot (chronic), ankle and M86.671 – Right foot M86.672 – Left
82 M89.7 Major osseous defect Code first underlying disease, if known, such as: aseptic necrosis of bone (M87.-) malignant neoplasm of bone (C40.-) osteolysis (M89.5) osteomyelitis (M86.-) osteonecrosis (M87.-) osteoporosis (M80.-, M81.-) periprosthetic osteolysis (T84.05-) M89.77 Major osseous defect, ankle and foot Major osseous defect of metatarsus, tarsus, toes M89.771 Major osseous defect, right ankle and foot M89.772 Major osseous defect, left ankle and foot
83 Additional Examples continuing with other ICD-10-CM Musculoskeletal Coding using the APMA Coding Resource Center
84 Chief Complaint: My right foot has this pain in the area under my big toe, feels like a pea in there.
HPI: This is a sharp pain, localized to the area immediately inferior to the 1st MTPJ sesamoid area, walking worsens the condition and the numbered Dr. Scholl’s inserts did not help.
85 Musculoskeletal: Inspection and palpation reveals the right tibial sesamoid is painful, increased temperature with localized pain. There is inflammation noted when compared to the left foot
Radiologic examination: AP, Lateral and Oblique views reveal hypertrophic changes to the right tibial sesamoid.
Impression: Sesamoiditis, tibial, right foot
86 87 88 ICD 9 ICD 10 733.99 Hypertrophy of M89.371 bone Hypertrophy of bone, right (sesamoiditis) ankle and foot
But is it a hypertrophy?
89 What about if it is an enthesopathy?
90 “Enthesopathy, unspecified Bone Spur NOS, Capsulitis NOS, Tendinits NOS)”
ICD 9 ICD 10 M77.51 Other enthesopathy of 733.99 right foot Hypertrophy of M77.9 bone Enthesopathy, unspecified (sesamoiditis) Bone Spur NOS, Capsulitis NOS,
Tendinits NOS)
91 What about the 2014 index, it says M25.8-
92 ICD 9 ICD 10 733.99 M25.871 Hypertrophy of Other specified joint disorders, bone ankle and foot, right (sesamoiditis)
You need to decide and use the correct verbiage offered in the example.
93 Chief Complaint: A 11 year old boy is here with his mom, stating that the bottom of his right heel hurts.
HPI: This is a sharp pain, localized to the calcaneus immediately inferiorly and is getting worse. It has been difficult walking and worsens with activity. Mom said she went to the store and followed the foot mapping from those numbered Dr. Scholl’s inserts, spent a lot of money but they did not help.
94 Musculoskeletal: Inspection and palpation reveals the right calcaneus has localized pain along the apophysis. There is inflammation noted when compared to the left foot
Radiologic examination: AP, Lateral and Oblique views reveal normal growth plate on the calcaneus however the more inferior aspect when compared to the left x-rays appears further apart by 2mm.
Impression: Calcaneal Apophysitis (Severs Disease), right foot
95 96 Just to be complete, here are the other juvenile osteochondrosis…..
97 98 ICD 9 ICD 10 732.5 Juvenile M92.61 Juvenile osteochondrosis osteochondrosis of of tarsus, right ankle - foot- Calcaneal Osteochondrosis (juvenile) of apophysitis calcaneum [Sever] M92.8 Other specified juvenile osteochondrosis Calcaneal apophysitis
So which diagnosis do you choose? 2 possibilities-based on your description
99 Chief Complaint: Doc the area that you did my fusion is swollen and hurts when walking
HPI: This is a sharp pain, localized to the 1st MTPJ right foot, seems unstable with walking he relates and is getting worse for 6 months did not want to come back was afraid of what you might say. It has been difficult walking and worsens with activity.
100 Musculoskeletal: Inspection and palpation reveals the right 1st MTPJ fusion site is not rigid, appears to have motion which was not intended. There is inflammation noted when compared to the left foot
Radiologic examination: AP, Lateral and Oblique views reveal the 1st MTPJ fusion site is not healed, there is shadowing within the fusion but it is not calcified.
Impression: Pseudoarthrosis of the 1st MTPJ, right foot
101 102 103 ICD 9 ICD 10 733.82 Nonunion of M96.0 fracture Pseudarthrosis after fusion or Pseudoarthrosis arthrodesis (bone)
104 Chief Complaint: Doc the area that I had my right foot surgery is very sore, swollen and bruised feeling.
HPI: Surgery was performed for a midfoot ostectomy, right foot. Area is ecchymotic, he has been icing and elevating the foot as prescribed and taking post-op pain medication hydrocodone every 4-6 hours.
105 Musculoskeletal: Inspection and palpation reveals the right foot 1st Metatarsal cuneiform joint surgical site is coapted well but there is extensive post operative ecchymosis subcutaneously.
Radiologic examination: AP, Lateral and Oblique views reveal the 1st metatarsal cuneiform site shows adequate resection of bone, none of the exostoses exist.
Impression: Post procedural hematoma of the musculoskeletal structure, 1st Metatarsal cuneiform joint, right foot, following the musculoskeletal procedure.
106 107 ICD 9 ICD 10
998.11 Hemorrhage complicating a M96.830 Postprocedural procedure hemorrhage and hematoma of a musculoskeletal structure 998.12 Hematoma following a musculoskeletal complicating a system procedure procedure
108 Next Webinar
Webinar 6: Injuries (S00-T88)
Thursday, April 17, 2014 at 8:00 PM ET
Presented by Andy Bhatia, DPM
Register at www.apma.org/icd10ishere
109 Questions?
110