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ICD-10-CM codes M00-M99 ICD-10-CM Guidelines for Coding & Reporting, Section I.C.13 1© Kathleen Peterson, MS, RHIA, CCS
R25 Abnormal involuntary movements ◦ Cramp and spasm R26 Abnormalities of gait and mobility R27 Other lack of coordination R29.6 Repeated falls ◦ Z91.81 History of falling, At risk for falling R Loss of height R Ocular torticollis © Kathleen Peterson, MS, RHIA, CCS2
Official Coding Guidelines, I.C.13.a-d Conditions coded to this chapter include ◦ M1a Chronic Gout ◦ M 10 Gout ◦ M30 Polyarteritis nodosa ◦ M26 Dentofacial anomalies, including malocclusion ◦ M27 Diseases of jaw ◦ M84.3- Stress fractures ◦ M84.4- through M84.6- Pathological fractures ◦ Bone, joint or muscle conditions that are recurrent or resulting from a healed injury © Kathleen Peterson, MS, RHIA, CCS 3
I.C.13.a. Site and laterality ◦ Site represents bone, joint or muscle involved ◦ Some conditions may have a code for “multiple sites” M10.09 Idiopathic gout, multiple sites ◦ If category does not have “multiple sites” code, then assign codes to indicate different sites M24.4- Recurrent dislocation of joint ◦ Bone vs. joint: Although bone affected may be at the joint, the site designation will be the bone. M Idiopathic aseptic necrosis of radius, ulna, and carpus © Kathleen Peterson, MS, RHIA, CCS4
I.C.13.b. Acute traumatic vs. chronic or recurrent musculoskeletal condition ◦ Any current, acute injury is coded to Chapter 19, Injury S83.014A Lateral dislocation of right patella, initial episode ◦ Bone, joint or muscle conditions that result from healed injury or are recurrent are usually found in Chapter 13, Musculoskeletal system M22.11 Recurrent incomplete dislocation of right knee ◦ If documentation is unclear whether acute vs. chronic or recurrent condition, query the provider. © Kathleen Peterson, MS, RHIA, CCS5
Joint Derangement ◦ Recurrent – see Derangement, joint, recurrent ◦ Due to current injury – see Derangement, joint, current injury and Derangement, joint Joint replacement ◦ Assign code for disease process resulting in joint replacement ◦ Assign Z96.6- for orthopedic joint replacement on subsequent admissions 6© Kathleen Peterson, MS, RHIA, CCS
ICD-10-CM coding guideline I.C.13.c Bone structure is weakened due to disease process ◦ Osteoporosis, osteomalacia, osteomyelitis, or neoplasm Review physician documentation ◦ Trauma fracture are coded to Injuries ◦ Pathological fracture M80, M84.4-, M84.5-, M84.6- 7 th characters are required to show initial, subsequent or sequela ◦ Stress fracture repetitive force see M84.3- Use additional external cause code(s) to identify cause of stress fracture Example: Y93.01, Activity walking, marching and hiking 7© Kathleen Peterson, MS, RHIA, CCS
Identify sites: pelvis, extremities, vertebrae ◦ Stress fractures of vertebrae are termed “fatigue fractures”. Identify episode of care with 7 th character ◦ Initial, subsequent, sequela M84.311A Stress fracture, right shoulder, initial episode M48.42xB Fatigue fracture of vertebra, cervical region, subsequent encounter for routine healing © Kathleen Peterson, MS, RHIA, CCS8
AInitial encounter for fracture Active treatment: surgical treatment, ED encounter, evaluation & treatment by new MD DSubsequent encounter for fracture with routine healing Code use for fracture aftercare - change or remove cast, remove external or internal fixation device, medication adjustment, follow-up visits following fracture treatment) GSubsequent encounter for fracture with delayed healing KSubsequent encounter for fracture with nonunion PSubsequent encounter for fracture with malunion SSequela © Kathleen Peterson, MS, RHIA, CCS 9
M66 Spontaneous rupture of synovium and tendon ◦ NOTE A spontaneous rupture is one that occurs when a normal force is applied to tissues that are inferred to have less than normal strength. M80 Osteoporosis with current pathological fracture ◦ NOTE Fragility fracture is defined as a fracture sustained with trauma no more than a fall from a standing height or less that occurs under circumstances that would not cause a fracture in a normal healthy bone. © Kathleen Peterson, MS, RHIA, CCS 10
ICD-10-CM coding guideline I.C.13.d. M81.- Osteoporosis without current pathological fracture ◦ Assign code even if patient has had fracture in past Z87.310, Personal hx of (healed) osteoporosis fracture, is also assigned with M81.- M80.- Osteoporosis with current pathological fracture ◦ Assign code for patients with current pathological fracture at time of encounter Assign code to identify fracture site Use for patients with osteoporosis who suffer a fracture, even if it was a minor fall or trauma, that would not usually break a normal, healthy bone. © Kathleen Peterson, MS, RHIA, CCS11
Includes kyphoscoliosis Types ◦ Idiopathic Infantile (birth through age 4) Juvenile (ages 5 through 10) Adolescent (ages 11 through 17) ◦ Secondary Neuromuscular or other ◦ Thoracogenic ◦ Other form ◦ Unspecified Identify site: cervical, cervicothoracic, thoracic, thoracolumbar, lumbar, lumbosacral, sacral/sacrococcygeal, unspecified © Kathleen Peterson, MS, RHIA, CCS12
Assign ICD-10-CM codes for: 1. Cervical spondylosis, C5-6, C Deformity of left ring finger, due to old flexor tendon laceration 3. Right hallux valgus © Kathleen Peterson, MS, RHIA, CCS13
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