Rheumatology ICD-10 documentation

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1 Rheumatology documentation Seven key impacts to documentation 1. Disease or disorder site 2. Acuity and/or encounter status of treatment 3. Etiology, causative agent, or disease type and injury/ poisoning cause, intent, activity at the time of the event and place event occurred 4. Underlying and associated conditions 5. Manifestations 6. Complications or adverse events 7. Supporting info such as lab values or socioeconomic key impacts to documentation Most commonly used diagnoses Name Name Dermatomyositis M33.00 Juvenile dermatopolymyositis, organ involvement unspecified M33.01 Juvenile dermatopolymyositis with respiratory involvement M33.02 Juvenile dermatopolymyositis with myopathy M33.09 Juvenile dermatopolymyositis with other organ involvement M33.10 Other dermatopolymyositis, organ involvement unspecified M33.11 Other dermatopolymyositis with respiratory involvement M33.12 Other dermatopolymyositis with myopathy M33.19 Other dermatopolymyositis with other organ involvement M33.90 Dermatopolymyositis, unspecified, organ involvement unspecified M33.91 Dermatopolymyositis, unspecified with respiratory involvement M33.92 Dermatopolymyositis, unspecified with myopathy M33.99 Dermatopolymyositis, unspecified with other organ involvement M36.0 Dermato(poly)myositis in neoplastic disease Refer to 7 key impacts of Documenatation 1

2 Name Name Polyarticular juvenile rheumatoid arthritis, chronic or unspecified M08.00 Unspecified juvenile rheumatoid arthritis of unspecified site M Unspecified juvenile rheumatoid arthritis, right shoulder M Unspecified juvenile rheumatoid arthritis, left shoulder M Unspecified juvenile rheumatoid arthritis, unspecified shoulder M Unspecified juvenile rheumatoid arthritis, right elbow M Unspecified juvenile rheumatoid arthritis, left elbow M Unspecified juvenile rheumatoid arthritis, unspecified elbow M Unspecified juvenile rheumatoid arthritis, right wrist M Unspecified juvenile rheumatoid arthritis, left wrist M Unspecified juvenile rheumatoid arthritis, unspecified wrist M Unspecified juvenile rheumatoid arthritis, right hand M Unspecified juvenile rheumatoid arthritis, left hand M Unspecified juvenile rheumatoid arthritis, unspecified hand M Unspecified juvenile rheumatoid arthritis, right hip M Unspecified juvenile rheumatoid arthritis, left hip M Unspecified juvenile rheumatoid arthritis, unspecified hip M Unspecified juvenile rheumatoid arthritis, right knee M Unspecified juvenile rheumatoid arthritis, left knee M Unspecified juvenile rheumatoid arthritis, unspecified knee M Unspecified juvenile rheumatoid arthritis, right ankle M Unspecified juvenile rheumatoid arthritis, left ankle M Unspecified juvenile rheumatoid arthritis, unspecified ankle M08.08 Unspecified juvenile rheumatoid arthritis, vertebrae M08.09 Unspecified juvenile rheumatoid arthritis, multiple sites 2

3 Name Name M08.20 Juvenile rheumatoid arthritis with systemic onset, unspecified site M Juvenile rheumatoid arthritis with systemic onset, right shoulder M Juvenile rheumatoid arthritis with systemic onset, left shoulder M Juvenile rheumatoid arthritis with systemic onset, unspecified shoulder M Juvenile rheumatoid arthritis with systemic onset, right elbow M Juvenile rheumatoid arthritis with systemic onset, left elbow M Juvenile rheumatoid arthritis with systemic onset, unspecified elbow M Juvenile rheumatoid arthritis with systemic onset, right wrist M Juvenile rheumatoid arthritis with systemic onset, left wrist M Juvenile rheumatoid arthritis with systemic onset, unspecified wrist M Juvenile rheumatoid arthritis with systemic onset, right hand M Juvenile rheumatoid arthritis with systemic onset, left hand M Juvenile rheumatoid arthritis with systemic onset, unspecified hand M Juvenile rheumatoid arthritis with systemic onset, right hip M Juvenile rheumatoid arthritis with systemic onset, left hip M Juvenile rheumatoid arthritis with systemic onset, unspecified hip M Juvenile rheumatoid arthritis with systemic onset, right knee M Juvenile rheumatoid arthritis with systemic onset, left knee M Juvenile rheumatoid arthritis with systemic onset, unspecified knee M Juvenile rheumatoid arthritis with systemic onset, right ankle M Juvenile rheumatoid arthritis with systemic onset, left ankle M Juvenile rheumatoid arthritis with systemic onset, unspecified ankle M08.28 Juvenile rheumatoid arthritis with systemic onset, vertebrae M08.29 Juvenile rheumatoid arthritis with systemic onset, multiple sites 3

4 Name Name M08.3 Juvenile rheumatoid polyarthritis (seronegative) M08.80 Other juvenile arthritis, unspecified site M Other juvenile arthritis, right shoulder M Other juvenile arthritis, left shoulder M Other juvenile arthritis, unspecified shoulder M Other juvenile arthritis, right elbow M Other juvenile arthritis, left elbow M Other juvenile arthritis, unspecified elbow M Other juvenile arthritis, right wrist M Other juvenile arthritis, left wrist M Other juvenile arthritis, unspecified wrist M Other juvenile arthritis, right hand M Other juvenile arthritis, left hand M Other juvenile arthritis, unspecified hand M Other juvenile arthritis, right hip M Other juvenile arthritis, left hip M Other juvenile arthritis, unspecified hip M Other juvenile arthritis, right knee M Other juvenile arthritis, left knee M Other juvenile arthritis, unspecified knee M Other juvenile arthritis, right ankle and foot M Other juvenile arthritis, left ankle and foot M Other juvenile arthritis, unspecified ankle M08.88 Other juvenile arthritis, other specified site M08.89 Other juvenile arthritis, multiple sites M08.90 Juvenile arthritis, unspecified, unspecified site M Juvenile arthritis, unspecified, right shoulder M Juvenile arthritis, unspecified, left shoulder M Juvenile arthritis, unspecified, unspecified shoulder M Juvenile arthritis, unspecified, right elbow M Juvenile arthritis, unspecified, left elbow M Juvenile arthritis, unspecified, unspecified elbow M Juvenile arthritis, unspecified, right wrist 4

5 Name Name Pauciarticular juvenile rheumatoid arthritis M Juvenile arthritis, unspecified, left wrist M Juvenile arthritis, unspecified, unspecified wrist M Juvenile arthritis, unspecified, right hand M Juvenile arthritis, unspecified, left hand M Juvenile arthritis, unspecified, unspecified hand M Juvenile arthritis, unspecified, right hip M Juvenile arthritis, unspecified, left hip M Juvenile arthritis, unspecified, unspecified hip M Juvenile arthritis, unspecified, right knee M Juvenile arthritis, unspecified, left knee M Juvenile arthritis, unspecified, unspecified knee M Juvenile arthritis, unspecified, right ankle M Juvenile arthritis, unspecified, left ankle M Juvenile arthritis, unspecified, unspecified ankle M08.98 Juvenile arthritis, unspecified, vertebrae M08.99 Juvenile arthritis, unspecified, multiple sites M08.40 Pauciarticular juvenile rheumatoid arthritis, unspecified site M Pauciarticular juvenile rheumatoid arthritis, right shoulder M Pauciarticular juvenile rheumatoid arthritis, left shoulder M Pauciarticular juvenile rheumatoid arthritis, unspecified shoulder M Pauciarticular juvenile rheumatoid arthritis, right elbow M Pauciarticular juvenile rheumatoid arthritis, left elbow M Pauciarticular juvenile rheumatoid arthritis, unspecified elbow M Pauciarticular juvenile rheumatoid arthritis, right wrist M Pauciarticular juvenile rheumatoid arthritis, left wrist M Pauciarticular juvenile rheumatoid arthritis, unspecified wrist M Pauciarticular juvenile rheumatoid arthritis, right hand M Pauciarticular juvenile rheumatoid arthritis, left hand 5

6 Name Name Pain in joint involving lower leg Pain in joint involving multiple sites Systemic lupus M Pauciarticular juvenile rheumatoid arthritis, unspecified hand M Pauciarticular juvenile rheumatoid arthritis, right hip M Pauciarticular juvenile rheumatoid arthritis, left hip M Pauciarticular juvenile rheumatoid arthritis, unspecified hip M Pauciarticular juvenile rheumatoid arthritis, right knee M Pauciarticular juvenile rheumatoid arthritis, left knee M Pauciarticular juvenile rheumatoid arthritis, unspecified knee M Pauciarticular juvenile rheumatoid arthritis, right ankle M Pauciarticular juvenile rheumatoid arthritis, left ankle M Pauciarticular juvenile rheumatoid arthritis, unspecified ankle M08.48 Pauciarticular juvenile rheumatoid arthritis, vertebrae M Pain in right knee M Pain in left knee M Pain in unspecified knee M25.50 Pain in unspecified joint M32.0 Drug-induced systemic lupus M32.10 Systemic lupus, organ or system involvement unspecified M32.11 Endocarditis in systemic lupus M32.12 Pericarditis in systemic lupus M32.13 Lung involvement in systemic lupus M32.14 Glomerular disease in systemic lupus M32.15 Tubulo-interstitial nephropathy in systemic lupus M32.19 Other organ or system involvement in systemic lupus M32.8 Other forms of systemic lupus M32.9 Systemic lupus, unspecified Systemic lupus (SLE) Specify any autoimmune, single organ, or singlecell type diseases Identify any drugs or chemicals associated with drug-induced SLE or systemic sclerosis List any underlying diseases or neoplasms e.g., multiple myeloma, hemophilia, ochronosis, etc. The Provider Specialty Tool Kit is meant to assist providers with documentation best practices necessary for the transition from -CM to -CM. This tool kit includes the most commonly used diagnoses for a specialty using 2012 claims data for top encounters and top number of dollars per diagnosis. The tool kit can be used as a quick reference guide for providers and can also be shared with Practice Managers. This tool kit is not meant to be a coding cross walk and therefore should not be used as such. Questions regarding this tool kit and/or should be submitted via to [email protected] Children s Healthcare of Atlanta Inc. All rights reserved. SYS ms.3/15 6

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