ICD-10-CM Coding Workbook for Orthopaedics. Specialty coding guidance for ICD-10-CM

Transcription

1 ICD-10-CM Coding Workbook for Orthopaedics Specialty coding guidance for ICD-10-CM 2017

2 Contents Introduction... 1 Overview of ICD Getting Ready for ICD Using This ICD-10-CM Workbook... 2 Workbook Guidelines... 3 Online Exams to Test Your ICD-10-CM Coding Skills... 4 Summary... 4 Case Studies and Questions... 5 Case Study #1 Total Knee Arthroplasty... 5 Case Study #2 Radial Shaft Fracture... 8 Case Study #3 Total Hip Arthroplasty...12 Case Study #4 Periprosthetic Fracture of Femur...14 Case Study #5 Trigger Finger Release...17 Case Study #6 Digital Neuroma...19 Case Study #7 Degenerative Joint Disease, Shoulder...21 Case Study #8 ACL Tear...23 Case Study #9 Radioulnar Synostosis...26 Case Study #10 Lunate Stress Fracture...28 Case Study #11 Fracture of Thumb...30 Case Study #12 Gangrene of Foot...32 Case Study #13 Idiopathic Osteoporosis...35 Case Study #14 Rupture of Quadriceps Tendon...37 Case Study #15 Wrist Laceration with Tendon Injury...40 Case Study #16 Cervical Stenosis with Myelopathy...43 Case Study #17 Rotator Cuff and Labral Tear of Shoulder...46 Case Study #18 ACL and Meniscus Injury, Knee...49 Case Study #19 Meniscal Tear and Osteochondral Fracture, Knee...51 Case Study #20 Degenerative Joint Disease, Shoulder...55 Case Study #21 Status Postlumbar Decompression with Osteoporosis...57 Case Study #22 Osteoarthritis and Myofascial Pain Syndrome...62 Case Study #23 Left Foot Pain...64 Case Study #24 Left Knee Pain...67 Case Study #25 Humeral Fracture...70 Case Study #26 Distal Fibular Fracture...73 Case Study #27 Planovalgus Feet with Myotonic Muscular Dystrophy...77 Case Study #28 Chronic Plantar Fasciitis...80 Case Study #29 Posterior Calf Pain...82 Case Study #30 Bunion and Hammer Toe...85 Case Study #31 Erythema of the Knee...89 Case Study #32 Chronic Pain...91 Case Study #33 Back and Shoulder Pain...94 Case Study #34 Carpal Tunnel Syndrome...98 Case Study #35 Lytic Lesion of Cervical Vertebrae Case Study #36 Patellar Tendon Rupture Case Study #37 Above-the-Knee Amputation Optum360, LLC i

3 Contents ICD-10-CM Coding Workbook for Orthopaedics Case Study #38 Avascular Necrosis of Hip Case Study #39 Neck Pain Following MVA Case Study #40 Shoulder Osteoarthritis Case Study #41 Trauma to Finger Case Study #42 Open Tibia Fibula Fracture Case Study #43 Transmetatarsal Amputation Case Study #44 Displaced Fifth Metacarpal Fracture Case Study #45 Follow-up for Tibial Plateau Fracture Case Study #46 Removal of Painful Instrumentation and Placement of L5-S1 Rods Answers and Rationales Case Study #1 Total Knee Arthroplasty Case Study #2 Radial Shaft Fracture Case Study #3 Total Hip Arthroplasty Case Study #4 Periprosthetic Fracture of Femur Case Study #5 Trigger Finger Release Case Study #6 Digital Neuroma Case Study #7 Degenerative Joint Disease, Shoulder Case Study #8 ACL Tear Case Study #9 Radioulnar Synostosis Case Study #10 Lunate Stress Fracture Case Study #11 Fracture of Thumb Case Study #12 Gangrene of Foot Case Study #13 Idiopathic Osteoporosis Case Study #14 Rupture of Quadriceps Tendon Case Study #15 Wrist Laceration with Tendon Injury Case Study #16 Cervical Stenosis with Myelopathy Case Study #17 Rotator Cuff and Labral Tear of Shoulder Case Study #18 ACL and Meniscus Injury, Knee Case Study #19 Meniscal Tear and Osteochondral Fracture, Knee Case Study #20 Degenerative Joint Disease, Shoulder Case Study #21 Status Postlumbar Decompression with Osteoporosis Case Study #22 Osteoarthritis and Myofascial Pain Syndrome Case Study #23 Left Foot Pain Case Study #24 Left Knee Pain Case Study #25 Humeral Fracture Case Study #26 Distal Fibular Fracture Case Study #27 Planovalgus Feet with Myotonic Muscular Dystrophy Case Study #28 Chronic Plantar Fasciitis Case Study #29 Posterior Calf Pain Case Study #30 Bunion and Hammer Toe Case Study #31 Erythema of the Knee Case Study #32 Chronic Pain Case Study #33 Back and Shoulder Pain Case Study #34 Carpal Tunnel Syndrome Case Study #35 Lytic Lesion of Cervical Vertebrae Case Study #36 Patellar Tendon Rupture Case Study #37 Above-the-Knee Amputation Case Study #38 Avascular Necrosis of Hip ii 2016 Optum360, LLC

4 ICD-10-CM Coding Workbook for Orthopaedics Contents Case Study #39 Neck Pain Following MVA Case Study #40 Shoulder Osteoarthritis Case Study #41 Trauma to Finger Case Study #42 Open Tibia Fibula Fracture Case Study #43 Transmetatarsal Amputation Case Study #44 Displaced Fifth Metacarpal Fracture Case Study #45 Follow-up for Tibial Plateau Fracture Case Study #46 Removal of Painful Instrumentation and Placement of L5-S1 Rods Appendix A. Quick Coding Reference How to Use Spinal Conditions ICD-10-CM Mapping Fractures ICD-10-CM Mapping Joint Conditions and Injuries ICD-10-CM Mapping Other Traumatic Injuries ICD-10-CM Mapping General Musculoskeletal ICD-10-CM Mapping Appendix B. ICD-10-CM Official Guidelines for Coding and Reporting Section I. Conventions, general coding guidelines and chapter specific guidelines Section II. Selection of Principal Diagnosis Section III. Reporting Additional Diagnoses Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services Optum360, LLC iii

5 Case Studies and Questions ICD-10-CM Coding Workbook for Orthopaedics Case Study #23 Left Foot Pain Description Consultation for left foot pain Chief Complaint Left foot pain History The patient is a basketball player for Optum University who was injured in a game one day prior. He jumped and came down twisting his foot and injuring it. He had an immediate onset of swelling and pain. The trainer taped up his foot and he was able to continue playing in the game. Following the game he was further examined by the trainer and had some tenderness around the navicular. The patient has been taped up firmly and in a walking boot since the game. He does have pain with any type of weightbearing activities and is limping a bit. He has not suffered any significant foot injuries in the past. The majority of the pain is located around the dorsal aspect of the hind and midfoot. Physical Examination Patient has swelling from the hindfoot out toward the midfoot. The arch is maintained however. Motion at the ankle and subtalar joints is preserved, and forefoot motion is intact. He complains of pain with adduction and abduction across the hindfoot, most of the discomfort presenting laterally. Motor strength is grossly intact, as is sensation. Pulses are strong and palpable. The ankle is not tender. There is no medial tenderness over the ATFL, along the deltoid, or the medial malleolus. His anterior drawer is solid. External rotation stress is not painful at the ankle. Tarsometatarsal joints 1, 2, and 3 are nontender. The majority of tenderness is found laterally along the calcaneocuboid joint and along the anterior process of the calcaneus. The patient notes some tenderness over the dorsolateral side of the talonavicular joint as well, although the medial talonavicular joint is nontender. Radiology Weightbearing radiographs of the foot show changes that appear chronic over the dorsal aspect of the navicular. There does not appear to be a definite fracture. Tarsometatarsal joints are anatomically aligned. Films of the ankle show no fractures but changes along the dorsal talonavicular joint. An MR scan was also reviewed, which shows some changes along the lateral side of the calcaneocuboid joint with disruption of the capsular area and lateral ligament. It also shows some changes to the dorsal talonavicular joint, but no significant marrow edema or definitive fracture line. Impression Left Chopart joint sprain Plan Continue with walking boot for weightbearing activities. Start a functional rehab program and progress back to activities as symptoms allow. Patient is aware that a prolonged duration of recovery is sometimes needed for this type of a hindfoot injury, and additional injury can occur if appropriate plan is not followed Optum360, LLC

6 Answers and Rationales ICD-10-CM Coding Workbook for Orthopaedics Case Study #23 Left Foot Pain Answers 1. Assign the correct ICD-10-CM diagnosis codes for the above encounter. S93.692A Other sprain of left foot, initial encounter Y93.67 Activity, basketball Y Basketball court as the place of occurrence of the external cause This type of foot sprain can be difficult to code due to the number of different ligaments found in the foot structure. The patient suffered a Chopart joint sprain, which is a sprain of the midtarsal region of the foot. It typically involves the dorsal calcaneocuboid ligament or the bifurcate ligament. In order to find the appropriate code, main term Sprain and subterm foot should be identified in the alphabetic index. The only ligaments listed under foot are the tarsal ligament and the tarsometatarsal ligament. The most accurate choice based on the knowledge gained about Chopart joint sprains is specified ligament NEC, which references S The tabular list indicates that seven characters are required for a complete code selection. Sixth character 2 represents the left foot and seventh character A indicates that this encounter is within the initial encounter phase of this injury. External cause codes provide additional information about the mechanism of injury. This was a twisting injury of the foot. In the Index to External Causes, main term Twisting and subterm excessive seem to be the only appropriate option. This listing tells the coder to see category Y93. This category includes the activity codes, which describe the type of activity the patient was taking part in when the twisting injury occurred. Main term Activity and subterm basketball reference code Y93.67, which when verified in the tabular list is deemed appropriate and complete. It is also possible to indicate where the injury occurred. Main term Place of occurrence and subterm basketball court reference code Y The tabular list verifies that this is the appropriate code choice. 2. Match the following bones of the foot and ankle with the correct definition. Bones Definitions a. Navicular 3 1. Sits on top of the calcaneus, also known as the ankle bone b. Calcaneus 2 2. Largest tarsal bone of the foot, also called the heel bone c. Cuboid 5 3. Small tarsal bone that sits at the top of the midfoot d. Talus 1 4. Rounded protuberances on each side of the ankle e. Malleolus 4 5. Small tarsal bone that sits toward the outside of the foot, in the midfoot area These bones are all part of the foot and ankle. It is vital to know and understand the bone structure of various parts of the body in order to report ICD-10-CM codes accurately Optum360, LLC

7 ICD-10-CM Coding Workbook for Orthopaedics Answers and Rationales 3. If this patient had endured a nondisplaced navicular fracture in his foot, which ICD-10-CM diagnosis code would be reported? a. S62.002A Unspecified fracture of navicular [scaphoid] bone of left wrist, initial encounter for closed fracture b. S62.035A Nondisplaced fracture of proximal third of navicular [scaphoid] bone of left wrist, initial encounter for closed fracture c. S92.255A Nondisplaced fracture of navicular [scaphoid] of left foot, initial encounter for closed fracture d. S62.015A Nondisplaced fracture of distal pole of navicular [scaphoid] bone of left wrist, initial encounter for closed fracture There is a navicular bone in the foot and the wrist, so it is important to be aware of which area is being treated and, therefore, being coded. In this instance, it is the navicular bone in the foot. A nondisplaced navicular fracture of the foot would be appropriately assigned to S with seventh character A representing the initial encounter. 4. What would be the appropriate additional external cause code if this injury came from being stepped on by one of the players on the other team? W50.0XXA Accidental hit or strike by another person, initial encounter If this injury was the result of the patient being stepped on by a player on the opposite team, there is an additional code that can be added to the current external cause codes already provided. Main term Stepped on by and subterm person in the Index to External Causes reference code W50.0. The tabular list indicates that seven characters are required for this code. Characters five and six are X placeholders. Character seven is an A to indicate the initial encounter for this injury. According to the ICD-10-CM Draft Official Guidelines for Coding and Reporting, Section I.C.20.a.4, it is appropriate to report as many external cause codes as necessary to completely explain the circumstances. 5. This patient returned for a follow-up visit three months later. He was having no further problems and seemed to be healthy, but given his role in athletics it was felt that he should have this routine follow-up visit. What is the appropriate first-listed ICD-10-CM diagnosis code for this visit? a. Z02.5 Encounter for examination for participation in sport b. Z47.89 Encounter for other orthopedic aftercare c. S93.692D Other sprain of left foot, subsequent encounter d. S93.692A Other sprain of left foot, initial encounter Based on the information provided in the ICD-10-CM Draft Official Guidelines for Coding and Reporting, Section I.C.19.a, seventh character D is used to indicate subsequent encounters. A subsequent encounter is any encounter that occurs after the active phase of treatment has concluded for which the patient is receiving routine follow-up care. In this instance, the patient was returning three months after his initial treatment. Based on the information provided in the question above, there was no active care still ongoing. This visit was simply for a routine aftercare visit to verify that the patient was still healing properly and could perform in athletics as needed Optum360, LLC 175