ICD-10 and Sports Medicine



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ICD-10 and Sports Medicine Steven M. Verno, CMBS, CEMCS, CMSCS, CPM-MCS Page 1 of 15

ICD-10 and Sports Medicine Copyright 2011 Steven M. Verno, CMBS, CEMCS, CMSCS, CPm-MCS November 1, 2011 Note: and ICD-10 are owned and copyrighted by the World Health Organization. The codes in this guide were obtained from the US Department of Health and Human Services, NCHS website. This guide does not contain ANY legal advice. This guide shows what specific codes will change to when becomes. Images were obtained from free public domain websites. This guide does NOT replace the final coding manual when published in 2013. For the past thirty-one (31) years, we have learned and used when coding for our providers. As someone once said, just when we learned the answers, they changed the questions. Also, for years, there has been rumor that ICD-10 would be replacing ICD-9, and now this will soon be a reality. ICD-10 will replace as of October 1, 2013. This can be found at https://www.cms.gov/icd10/11b_2011_icd10pcs.asp. As of October 1, 2011, you have 24 months to be ready for There is an old saying in coding, If it isn t documented, it doesn t exist or it didn t happen. When ICD-10 becomes effective, it s success is dependent on the provider s documentation. If the documentation shows, OM, many of us know this means Otitis Media. Under, you have the following codes for OM: 382.9 - Unspecified otitis media, Otitis media: NOS, acute NOS, chronic NOS ICD-10 will require more work on the provider to document the exact type of diagnosis found with the patient. ICD-10 opens more with the anatomical area affected and allows for coding of chronic modalities. Under, you have the following codes for Otitis Media: H66.9 Otitis media, unspecified H66.90 Otitis media, unspecified, unspecified ear H66.91 Otitis media, unspecified. right ear H66.92 Otitis media, unspecified, left ear Page 2 of 15

H66.93 Otitis media, unspecified, bilateral As you can see, under, you have one code you can select if the documentation is not specific. The patient may have been a child with ear pain in both ears, but all the doctor wrote is OM and nothing more. was very forgiving to the documentationally challenged provider and coder. Under, you have a possibility of five (5) codes and you do need more anatomical information to select the best possible code. Using a pure unspecified code such as H66.9 could cause your claim to be pended or placed under review, which could cause a significant revenue loss for the practice. Lets look at some of the most used codes in Sports Medicine. Please understand that this guide does NOT contain all codes used and these codes could change by 2013. This guide does not take the place of coding or published coding manuals. NUMERICAL ORDER BY 717.83 - Old disruption of anterior cruciate ligament M23.611 Other spontaneous disruption of anterior cruciate ligament of right M23.612 Other spontaneous disruption of anterior cruciate ligament of left M23.619 Other spontaneous disruption of anterior cruciate ligament of unspecified 719.46 - Pain in joint; lower leg, Fibula, Knee joint, Patella, Tibia M79.661 Pain in right lower leg M79.662 Pain in left lower leg M79.669 Pain in unspecified lower leg 719.47 - Pain in joint; ankle and foot, Ankle joint, Digits [toes], Metatarsus, Phalanges, foot, Tarsus, Other joints in foot Page 3 of 15

M25.571 Pain in right ankle M25.572 Pain in left ankle M25.579 Pain in unspecified ankle 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) 726.12 - Bicipital tenosynovitis M65.811 Other synovitis and tenosynovitis, right shoulder M65.812 Other synovitis and tenosynovitis, left shoulder M65.819 Other synovitis and tenosynovitis, unspecified shoulder 729.5 - Pain in limb 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 Page 4 of 15

M79.606 Pain in leg, unspecified M79.609 Pain in unspecified limb 831.01 - Shoulder; closed dislocation; anterior dislocation of humerus M24.411 Recurrent dislocation, right shoulder M24.412 Recurrent dislocation, left shoulder M24.419 Recurrent dislocation, unspecified shoulder M24.311 Pathological dislocation of right shoulder, not elsewhere classified M24.312 Pathological dislocation of left shoulder, not elsewhere classified M24.319 Pathological dislocation of unspecified shoulder, not elsewhere classified S43.001A Unspecified subluxation of right shoulder joint, initial encounter S43.001D Unspecified subluxation of right shoulder joint, subsequent encounter S43.001S Unspecified subluxation of right shoulder joint, sequela S43.004A Unspecified dislocation of right shoulder joint, initial encounter S43.004D Unspecified dislocation of right shoulder joint, subsequent encounter S43.004S Unspecified dislocation of right shoulder joint, sequela S43.014A Anterior dislocation of right humerus, initial encounter S43.014D Anterior dislocation of right humerus, subsequent encounter S43.014S Anterior dislocation of right humerus, sequela S43.015A Anterior dislocation of left humerus, initial encounter S43.015D Anterior dislocation of left humerus, subsequent encounter S43.015S Anterior dislocation of left humerus, sequela S43.016A Anterior dislocation of unspecified humerus, initial encounter S43.016D Anterior dislocation of unspecified humerus, subsequent encounter S43.016S Anterior dislocation of unspecified humerus, sequela Page 5 of 15

S43.021A Posterior subluxation of right humerus, initial encounter S43.021D Posterior subluxation of right humerus, subsequent encounter S43.021S Posterior subluxation of right humerus, sequela S43.031A Inferior subluxation of right humerus, initial encounter S43.031D Inferior subluxation of right humerus, subsequent encounter S43.031S Inferior subluxation of right humerus, sequela 836.0 - Tear of medial cartilage or meniscus of, current, Bucket handle tear: NOS current injury, medial meniscus current injury M23.231 Derangement of other medial meniscus due to old tear or injury, right M23.232 Derangement of other medial meniscus due to old tear or injury, left M23.239 Derangement of other medial meniscus due to old tear or injury, unspecified M23.241 Derangement of anterior horn of lateral meniscus due to old tear or injury, right M23.242 Derangement of anterior horn of lateral meniscus due to old tear or injury, left M23.249 Derangement of anterior horn of lateral meniscus due to old tear or injury, unspecified M23.251 Derangement of posterior horn of lateral meniscus due to old tear or injury, right M23.252 Derangement of posterior horn of lateral meniscus due to old tear or injury, left M23.259 Derangement of posterior horn of lateral meniscus due to old tear or injury, unspecified M23.261 Derangement of other lateral meniscus due to old tear or injury, right M23.262 Derangement of other lateral meniscus due to old tear or injury, left Page 6 of 15

M23.269 Derangement of other lateral meniscus due to old tear or injury, unspecified M23.300 Other meniscus derangements, unspecified lateral meniscus, right M23.301 Other meniscus derangements, unspecified lateral meniscus, left M23.302 Other meniscus derangements, unspecified lateral meniscus, unspecified M23.303 Other meniscus derangements, unspecified medial meniscus, right M23.304 Other meniscus derangements, unspecified medial meniscus, left M23.305 Other meniscus derangements, unspecified medial meniscus, unspecified M23.306 Other meniscus derangements, unspecified meniscus, right M23.307 Other meniscus derangements, unspecified meniscus, left M23.309 Other meniscus derangements, unspecified meniscus, unspecified M23.311 Other meniscus derangements, anterior horn of medial meniscus, right M23.312 Other meniscus derangements, anterior horn of medial meniscus, left M23.319 Other meniscus derangements, anterior horn of medial meniscus, unspecified M23.321 Other meniscus derangements, posterior horn of medial meniscus, right M23.322 Other meniscus derangements, posterior horn of medial meniscus, left M23.329 Other meniscus derangements, posterior horn of medial meniscus, unspecified M23.331 Other meniscus derangements, other medial meniscus, right M23.332 Other meniscus derangements, other medial meniscus, left M23.339 Other meniscus derangements, other medial meniscus, unspecified M23.341 Other meniscus derangements, anterior horn of lateral meniscus, right M23.342 Other meniscus derangements, anterior horn of lateral meniscus, left M23.349 Other meniscus derangements, anterior horn of lateral meniscus, unspecified M23.351 Other meniscus derangements, posterior horn of lateral meniscus, right Page 7 of 15

M23.352 Other meniscus derangements, posterior horn of lateral meniscus, left M23.359 Other meniscus derangements, posterior horn of lateral meniscus, unspecified M23.361 Other meniscus derangements, other lateral meniscus, right M23.362 Other meniscus derangements, other lateral meniscus, left M23.369 Other meniscus derangements, other lateral meniscus, unspecified 836.1 - Tear of lateral cartilage or meniscus of, current M23.200 Derangement of unspecified lateral meniscus due to old tear or injury, right M23.201 Derangement of unspecified lateral meniscus due to old tear or injury, left M23.202 Derangement of unspecified lateral meniscus due to old tear or injury, unspecified M23.203 Derangement of unspecified medial meniscus due to old tear or injury, right M23.204 Derangement of unspecified medial meniscus due to old tear or injury, left M23.205 Derangement of unspecified medial meniscus due to old tear or injury, unspecified M23.206 Derangement of unspecified meniscus due to old tear or injury, right M23.207 Derangement of unspecified meniscus due to old tear or injury, left M23.209 Derangement of unspecified meniscus due to old tear or injury, unspecified M23.211 Derangement of anterior horn of medial meniscus due to old tear or injury, right M23.212 Derangement of anterior horn of medial meniscus due to old tear or injury, left M23.219 Derangement of anterior horn of medial meniscus due to old tear or injury, unspecified M23.221 Derangement of posterior horn of medial meniscus due to old tear or injury, right Page 8 of 15

M23.222 Derangement of posterior horn of medial meniscus due to old tear or injury, left M23.229 Derangement of posterior horn of medial meniscus due to old tear or injury, unspecified M23.231 Derangement of other medial meniscus due to old tear or injury, right M23.232 Derangement of other medial meniscus due to old tear or injury, left M23.239 Derangement of other medial meniscus due to old tear or injury, unspecified M23.241 Derangement of anterior horn of lateral meniscus due to old tear or injury, right M23.242 Derangement of anterior horn of lateral meniscus due to old tear or injury, left M23.249 Derangement of anterior horn of lateral meniscus due to old tear or injury, unspecified M23.251 Derangement of posterior horn of lateral meniscus due to old tear or injury, right M23.252 Derangement of posterior horn of lateral meniscus due to old tear or injury, left M23.259 Derangement of posterior horn of lateral meniscus due to old tear or injury, unspecified M23.261 Derangement of other lateral meniscus due to old tear or injury, right M23.262 Derangement of other lateral meniscus due to old tear or injury, left M23.269 Derangement of other lateral meniscus due to old tear or injury, unspecified M23.300 Other meniscus derangements, unspecified lateral meniscus, right M23.301 Other meniscus derangements, unspecified lateral meniscus, left M23.302 Other meniscus derangements, unspecified lateral meniscus, unspecified M23.303 Other meniscus derangements, unspecified medial meniscus, right M23.304 Other meniscus derangements, unspecified medial meniscus, left M23.305 Other meniscus derangements, unspecified medial meniscus, unspecified Page 9 of 15

M23.306 Other meniscus derangements, unspecified meniscus, right M23.307 Other meniscus derangements, unspecified meniscus, left M23.309 Other meniscus derangements, unspecified meniscus, unspecified M23.311 Other meniscus derangements, anterior horn of medial meniscus, right M23.312 Other meniscus derangements, anterior horn of medial meniscus, left M23.319 Other meniscus derangements, anterior horn of medial meniscus, unspecified M23.321 Other meniscus derangements, posterior horn of medial meniscus, right M23.322 Other meniscus derangements, posterior horn of medial meniscus, left M23.329 Other meniscus derangements, posterior horn of medial meniscus, unspecified M23.331 Other meniscus derangements, other medial meniscus, right M23.332 Other meniscus derangements, other medial meniscus, left M23.339 Other meniscus derangements, other medial meniscus, unspecified M23.341 Other meniscus derangements, anterior horn of lateral meniscus, right M23.342 Other meniscus derangements, anterior horn of lateral meniscus, left M23.349 Other meniscus derangements, anterior horn of lateral meniscus, unspecified M23.351 Other meniscus derangements, posterior horn of lateral meniscus, right M23.352 Other meniscus derangements, posterior horn of lateral meniscus, left M23.359 Other meniscus derangements, posterior horn of lateral meniscus, unspecified M23.361 Other meniscus derangements, other lateral meniscus, right M23.362 Other meniscus derangements, other lateral meniscus, left M23.369 Other meniscus derangements, other lateral meniscus, unspecified Page 10 of 15

840.70 Sprains/strains; superior glenoid labruim lesion, SLAP lesion S43.431A - Superior glenoid labrum lesion of right shoulder, initial encounter S43.432A - Superior glenoid labrum lesion of left shoulder, initial encounter S43.439A - Superior glenoid labrum lesion of unspecified shoulder, initial encounter Sports medicine will be a challenge for the provider to ensure accurate and anatomical documentation. Coding for ICD-10 appears to be no different than that of ICD-9, but documentation will be the success or failure of ICD-10. Improper or lack of documentation will only delay claims processing and will decrease practice revenue. Under, you have the following: Page 11 of 15 Chapter 1: Infectious and Parasitic Diseases (001-139) Chapter 2: Neoplasms (140-239) Chapter 3: Endocrine, Nutritional, and Metabolic Diseases and Immunity Disorders (240-279) Chapter 4: Diseases of Blood and Blood Forming Organs (280-289) Chapter 5: Mental Disorders (290-319) Chapter 6: Diseases of Nervous System and Sense Organs (320-389) Chapter 7: Diseases of Circulatory System (390-459) Chapter 8: Diseases of Respiratory System (460-519) Chapter 9: Diseases of Digestive System (520-57 Chapter 10: Diseases of Genitourinary System (580-629) Chapter 11: Complications of Pregnancy, Childbirth, and the Puerperium (630-677) Chapter 12: Diseases Skin and Subcutaneous Tissue (680-709) Chapter 13: Diseases of Musculoskeletal and Connective Tissue (710-739) Chapter 14: Congenital Anomalies (740-759) Chapter 15: Newborn (Perinatal) Guidelines (760-779) Chapter 16: Signs, Symptoms and Ill-Defined Conditions (780-799) Chapter 17: Injury and Poisoning (800-999) Chapter 18: Classification of Factors Influencing Health Status and Contact with Health Service (Supplemental V01-V84) and Supplemental Classification of External Causes of Injury and Poisoning (E-codes, E800- E999) Under ICD-10, you have the following: Chapter 1: Certain infectious and parasitic diseases (A00-B99) Chapter 2: Neoplasms (C00-D48) Chapter 3: Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) Chapter 4: Endocrine, nutritional and metabolic diseases (E00-E90) Chapter 5: Mental and behavioral disorders (F01-F99)

Chapter 6: Diseases of the nervous system (G00-G99) Chapter 7: Diseases of the eye and adnexa (H00-H59) Chapter 8: Diseases of the ear and mastoid process (H60-H95) Chapter 9: Diseases of the circulatory system (I00-I99) Chapter 10: Acute upper respiratory infections (J00-J06) Chapter 11: Diseases of oral cavity and salivary glands (K00-K14) Chapter 12: Diseases of the skin and subcutaneous tissue (L00-L99) Chapter 13: Diseases of the musculoskeletal system and connective tissue (M00-M99) Chapter 14: Diseases of the genitourinary system (N00-N99) Chapter 15: Pregnancy, childbirth and the puerperium (O00-O99) Chapter 16: Certain conditions originating in the perinatal period (P00-P96) Chapter 17 Congenital malformations, deformations and chromosomal abnormalities (Q00-Q99) Chapter 18: Symptoms and signs involving the circulatory and respiratory systems (R00- R09) Chapter 19: Injury, poisoning and certain other consequences of external causes (S00- T98) Chapter 20: External causes of morbidity (V01-Y98) Factors influencing health status and contact with health services (Z00-Z99) E Codes will become V-Y Codes V Codes will become Z Codes. The Table of Drugs and Biologicals that were 900 series codes and E Codes are now T Codes. The proposed effective date for ICD-10 is October 1, 2013. So, what do we have to do? Retraining Staff Coders with training and certification need to undergo ICD-10 familiarization training to show coding using ICD-10 codes is not going to be difficult. Untrained staff members in coding positions must undergo training and they should also undergo certification. While certification is not mandated by State or Federal law, Certification assures that the coder can code per established standards. AAPC Coders will need to undergo retesting for certification. PAHCS and POMAA certified coders do not. Providers need training to be more detailed with health record documentation and the importance of how their documentation improves coding and improves practice revenue. Billers will need to have knowledge of ICD-10 to ensure claims go out with the appropriate ICD-10 codes and to fight claim denials due to coding issues. Untrained billing staff members should undergo training and certification as a medical biller. Page 12 of 15

New Manuals ICD-10 Manuals will need to be obtained and used. Updated Software Medical Billing software needs to be updated to include both and ICD-10. This is because with an October 1, 2013 proposed effective date, Claims for September 30 th and before September 30 th dates of service will still use ICD-9 Codes. You may have a patient who was seen under that did not provide insurance information and after 10/1/13, the patient reveals coverage, so the claim must go out using the ICD that was in effect. As an example, Mr. Smith was seen on July 1, 2011. The ICD code set in effect was. Mr. Smith presented himself as uninsured or self pay. You billed Mr. Smith who ignored your statements. Mr. Smith s account was sent to your debt collection agency on December 2, 2011. It is now November 2, 2012. Mr. Smith tries to obtain a home loan but is denied because your bill is unpaid. Mr. Smith files a complaint with the Centers for Medicare and Medicaid Services saying he had health insurance with Medicare and you failed to bill Medicare. CMS send you a stern letter but you inform CMS that Mr. Smith failed to identify himself as a Medicare patient and he failed to provide any information that could allow you to check to see if he had Medicare or submit a claim. CMS responds that you should send a claim to your Medicare MAC. You check and the claim would not be denied for timely filing. The claim should be sent to your Medicare MAC using codes because the ICD-9 codes were the code set in effect on the day Mr. Smith was seen. You also need to contact your clearinghouse, software company and insurance company regarding ANSI 5010 testing. Medicare requires ANSI 5010 testing to be completed by 12/31/2011. Contact your Medicare carrier to find out what they require from you so that you will have your testing completed in 61 days as of November 1, 2011 Updated Carrier Policies and Procedures Providers who are contracted and have agreed to carrier coding policies should be reviewing these policies and to make sure the contracted carrier is ready to accept the new codes. ABC Insurance may have a policy regarding cranialrectalectomies where the diagnosis for medical necessity is X000. Mr. Johnson is requesting a a cranialrectalectomy. His diagnosis is V111, so having a diagnosis of V111 wouldn t make providing a cranialrectalectomy medically necessary, therefore ABC Insurance would deny the procedure. You should find out if there are going to be any claims payment delays due to the changeover to ICD-10 as this may affect contract payment timeframes. Updated Compliance Plans Practices and Billing Companies should update their compliance plans regarding ICD-10 coding. Extra attention should be directed to performing routine internal audits of charts and claims Updated Coding Denial Appeals If the billing company is using a cookie cutter appeal, then the appeals should be reviewed and updated to conform to ICD-10 standards. Page 13 of 15

Updated Superbills If the practice is using a superbill that contains ICD-9 codes, these should be replaced with the appropriate ICD-10 code(s). Fraud and Abuse Continue to fight fraud, abuse and any up/downcoding issues. As with any changes there is always the fear that using something new is better resolved by downcoding a claim to remain under the radar Finding more codes available could lead to temptation to upcode or to submit a false claim to increase practice revenue. If we use the time we have been given for preparation, the transition from ICD-9 to ICD- 10 can be very seamless. The key to the successful use and transition to ICD-10 is going to ensure our Providers are aware of their responsibility towards better documentation of the patient s medical condition(s). Use the following formula: PPD = Lawsuits and LOR (Loss of Revenue). (PXSS Poor Documentation = Lawsuits and LOR. I can always be reached at steve_verno@yahoo.com That is steve_verno. I wish all much success. Steven M. Verno Page 14 of 15

About Steve Verno: Steve is a Certified Medical Billing Specialist (CMBS), a Certified Emergency Care Coding Specialist (CEMCS), a Certified Multispecialty Coding Specialist (CMSCS) and a Certified Practice Manager-Medical Coding Specialist (CPM-MCS). Steve s specialties include emergency medicine, family practice, internal medicine, pediatrics, urgent care, appeals, accounts receivables recovery (AR Recovery), ERISA,, provider health insurance contracting, fraud and abuse and compliance. Steve is a practice manager and Director of Reimbursement for an emergency care provider practice. He is a retired American Red Cross Health and Safety Instructor Trainer. A graduate of the American Red Cross College. A coding and billing instructor for the Medical Association of Billers, a coding and billing instructor/consultant to the Professional Association of Healthcare Coding Specialists, a Professor of Medical Coding and Billing at Everest University (currently on medical leave due to a stroke), a coding and billing instructor/advisor to the Lake Sumter Medical Society, a coding and billing instructor with The Coding Institute, a member of the Medical Economics Committee of the Florida College of Emergency Physicians, a contributing writer for the Insurance handbook for the Medical Office, an editorial board member of Billing-Coding Advantage, the Medical Association of Billers, and is an member of the Advisory Board of the Physician Office Managers Association of America. Steve also provides free coding and billing guidance on several medical coding and billing forums. In the past ten years, Steve has provided more than 10,000 answers on these forums. Page 15 of 15

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