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Code for Tailor's Bunion, Left Foot

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Code for Tailor's Bunion, Left Foot Diseases of the Musculoskeletal System and Connec6ve Tissue M00 – M50 (Part 2) Presented by Lawrence San1, DPM, FASPS WeBinar 4B: Thursday, March 6, 2014 1 APMA Educaonal Informaon: ICD-10 Webinars • Register for upcoming webinars • View archived recordings • Download PDF versions of each presentaon • apma.org/icd10 or apma.org/webinars Coding Resource Center • apmacodingrc.org Quesons • Contact the Health Policy and Prac1ce Department • [email protected] or 301-581-9200 2 ICD-10-CM Resources www.apma.org/icd10 3 APMA Coding Resource Center www.apmacodingrc.org • ICD-9 to ICD-10 crosswalks are now available. 4 REVIEW OF SOME OF THE ESSENTIAL GUIDELINES AND INSTRUCTIONS FOR CHAPTER 13 (M00 – M50) 5 Specific Coding Guidelines for Chapter 13 (M00 – M99) Site and laterality • Most of the codes within Chapter 13 have site and laterality designaons. The site represents the bone, joint or the muscle involved. • Where more than one bone, joint or muscle is usually involved, such as osteoarthri1s, there is a “mul1ple sites” code available. • For categories where no mul1ple site code is provided and more than one bone, joint or muscle is involved, mul1ple codes should be used to indicate the different sites involved. 6 Specific Coding Guidelines for Chapter 13 (M00 – M99) Bone versus joint • For certain condi1ons, the bone may be affected at the upper or lower end, (e.g., avascular necrosis of bone, M87, Osteoporosis, M80, M81). Though the por1on of the bone affected may be at the joint, the site designaon will be the bone, not the joint. 7 Specific Coding Guidelines for Chapter 13 (M00 – M99) • Chronic or recurrent condi1ons should generally be coded with a code from chapter 13. • If it is difficult to determine from the documentaon in the record which code is best to describe a condi1on, query the provider. 8 Specific Coding Guidelines for Chapter 13 (M00 – M99) Coding of Pathologic Fractures • 7th character A is for use on a paent that is receiving ini1al treatment for the fracture. • 7th character, D is to be used for encounters aer the ini1al treatment for the fracture. • The other 7th characters, listed under each subcategory in the Tabular List, are to be used for subsequent encounters for treatment of problems associated with the healing, such as malunions, nonunions, and sequelae. 9 Specific Coding Guidelines for Chapter 13 (M00 – M99) Coding of Pathologic Fractures • Care for complicaons of surgical treatment for fracture repairs during the healing or recovery phase should be coded with the appropriate complicaon codes. 10 Specific Coding Guidelines for Chapter 13 (M00 – M99) Osteoporosis • Osteoporosis is a systemic condi1on, meaning that all bones of the musculoskeletal system are affected. • Site is not a component of the codes under category M81, Osteoporosis without current pathological fracture. • The site codes under category M80, Osteoporosis with current pathological fracture, iden1fy the site of the fracture, not the osteoporosis. 11 Diseases of the Musculoskeletal System and Connecve Tissue (M00-M50) • Use an external cause code following the code for the musculoskeletal condi1on, if applicable, to iden1fy the cause of the musculoskeletal condi1on. 12 REVIEW OF EXCLUDES NOTES 13 EXCLUDES NOTES • Excludes1 note – Indicates that code iden1fied in the note and code where the note appears cannot be reported together because the 2 condi1ons cannot occur together. Example: E10 Type 1 Diabetes mellitus Excludes1: diabetes mellitus due to underlying condi1on (E08.-) drug or chemical induced diabetes mellitus (E09.-) gestaonal diabetes (O24.4-) hyperglycemia NOS (R73.9) neonatal diabetes mellitus (P70.2) type 2 diabetes mellitus (E11.-) 14 EXCLUDES NOTES • Excludes2 note – Indicates that condi1on iden1fied in the note is not part of the condi1on represented by the code where the note appears, so both codes may be reported together if the paent has both condi1ons. Example: L89 Pressure ulcer Excludes2: diabe1c ulcers (E08.621, E08.622, E09.621, E09.622, E10.621, E10.622, E11.621, E11.622, E13.621, E13.622) non-pressure chronic ulcer of skin (L97.-) skin infecons (L00-L08) varicose ulcer (I83.0, I83.2) 15 Painful Hallux Valgus – Le Foot In this presentaon, we will learn to code using the new ICD – 10 classificaon a paent who presents with: 1. Hallux valgus of the lee foot 2. Osteoarthri1s of the lee foot and ankle 3. Pain in the lee limb 16 Painful Hallux Valgus – Le Foot (Inial Visit) Consultaon: Referring physician: Dr. XXXXXXX Chief Complaint: Mr. jones, a 56 year old male, presents for an ini1al visit with a painful bunion on his lee foot. 17 Painful Hallux Valgus – Le Foot (Inial Visit) History of present illness: He states that the lee bunion has been hur1ng him for about 3 months. He has discomfort when he ambulates with shoes or sneakers. Taking his shoes off helps to make it feel beker. He does not remember any trauma and this is not work related. Locaon of injury: N/A 18 Painful Hallux Valgus – Le Foot (Inial Visit) Lee foot - Foot type – pes planus Normal ROM - subtalar, midtarsal, and ankle joints Forefoot reveals a moderate to severe hallux valgus deformity with par1al ROM Tenderness noted on both dorsiflexion and plantarflexion of hallux Tenderness on palpaon of medial eminence of bunion No signs of infecon Muscle power/tone – WNL 19 Painful Hallux Valgus – Le Foot (Inial Visit) Radiological: Review of paent’s radiographs reveal a hallux valgus deformity with degenerave changes on the lee foot. Osteophytes noted on the head of the first metatarsal with subchondral bone cysts. 20 Painful Hallux Valgus – Le Foot (Inial Visit) Assessment: 1. Hallux valgus, lee foot 2. Osteoarthri1s lee foot and ankle 3. Pain in lee hallux Plan: 1. Rx: Celebrex 200 mg. daily 2. Discussed with paent beker shoe gear with custom- made ortho1cs 3. Surgical op1ons were discussed 4. Paent to return for follow-up in one week 21 Coding This Encounter Using ICD - 9 Hallux Valgus – 735.0 Osteoarthri1s of foot and ankle – 715.17 Pain in joint – 719.47 22 Coding This Encounter Using ICD - 10 Code for Hallux Valgus: Go to Chapter 13 - Diseases of the Musculoskeletal System and Connec1ve Tissue (M00-M99). M20 - Acquired deformi1es of fingers and toes. M20.1 - Hallux valgus (acquired). M20.10 - Hallux valgus (acquired), unspecified foot. M20.12 Hallux valgus (acquired), lee foot. 23 Coding This Encounter Using ICD - 10 Code for osteoarthri1s lee foot: M19.0 - Primary osteoarthri1s of other joints. M19.07 - Primary osteoarthri1s ankle and foot. M19.072 Primary osteoarthri1s, lee ankle and foot. 24 Coding This Encounter Using ICD - 10 Code for pain in lee hallux: M25 - Other joint disorder M25.5- Pain in joint M25.50 - Pain in unspecified joint M25.57 - Pain in ankle and joints of foot M25.572 Pain in lee ankle and joints of foot 25 Comparing ICD-9 and ICD-10 ICD-9 ICD-10 M20.12 - Hallux valgus 735.0 - Hallux Valgus (acquired), lee foot M19.072 - Primary 715.17 - Osteoarthri1s of osteoarthri1s, lee ankle foot and ankle and foot M25.572 - Pain in lee 719.47 - Pain in joint ankle and joints of foot 26 Coding This Encounter Using ICD - 10 The codes for this ini1al encounter of a paent with a painful Hallux Valgus of the lee foot would be: ICD – 10: M20.12 Hallux valgus (acquired), lee foot. M19.072 Primary osteoarthri1s, lee ankle and foot. M25.572 Pain in lee ankle and joints of foot 27 Painful Ankle Right Ankle In this presentaon, we will learn to code using the new ICD – 10 classificaon a paent who presents with: 1. Oteoarthrosis, localized, secondary to previous trauma, right ankle 2. Loose body in right ankle 3. Chronic right ankle sprain 4. Pain in right limb 28 Painful Right Ankle (Inial Visit) Consultaon: Referring physician: Dr. XXXXXXX Chief Complaint: Mr. Smith, a 30 year old male presents for an ini1al visit with pain in his right ankle. 29 Painful Right Ankle (Inial Visit) History of present illness: He states that his right ankle has been annoying him for about 3 years, but now the discomfort is causing him to limp. The paent recalls spraining his right ankle about 3 years ago while playing basketball. He was treated in the emergency room with a soe cast and was told that he had a bad sprain. He wore the soe cast for 2 weeks. He occasionally takes Motrin, 400mg, to help manage the discomfort. Locaon of injury: Playground, 3 years ago 30 Painful Right Ankle (Inial Visit) Right foot and ankle – Normal ROM of the subtalar and midtarsal joints. Limited and painful ROM of the ankle joint, especially dorsiflexion. Ankle joint appears stable. Pain on dorsiflexion and plantarflexion of the ankle. Tenderness on palpaon of the anterior aspect of the ankle. Paent ambulates with a slight limp. No edema noted. No signs of infecon. Muscle power/tone - wnl 31 Painful Right Ankle (Inial Visit) Radiological: Review of paent’s radiographs reveal a loose body located on the lateral aspect of the right ankle, dorsal to the talus. Osteophytes noted on the lateral aspect of the talus. There are no other fractures or dislocaons. 32 Painful Right Ankle (Inial Visit) Assessment: 1. Oteoarthrosis, localized, secondary to previous trauma 2. Loose body in ankle 3. Chronic ankle sprain 4. Pain in limb Plan: 1. Rx: Celebrex 200 mg. daily 2. Dispensed CAM walker, to be worn daily. 3. Surgical op1ons were discussed. 4. Paent to return for follow-up in one week 33 Coding This Encounter Using ICD - 9 Oteoarthrosis, localized, secondary, ankle - 715.27 Loose body in ankle - 718.17 Chronic ankle sprain - 845.00 Pain in limb - 729.5 34 Coding This Encounter Using ICD - 10 Code for osteoarthrosis, localized, secondary, right ankle: Go to chapter 13 - Diseases of the musculoskeletal system and connec1ve 1ssue (M00-M99).
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