The changes to fracture coding in ICD-10-CM have received plenty of attention since coders first saw the expanded code choices. In some cases, coders went from having two codes for a particular fracture in ICD-9-CM to several hundred codes in ICD-10-CM.
However, fractures are not the only orthopedic conditions that may require additional documentation for ICD-10-CM. Coders will need more details in order to report sprains, strains, and dislocations as well.
Laterality and encounter
The ICD-10-CM codes for strains, sprains, and dislocations can include significantly more detail about the specific site of the dislocation, including laterality (right, left, or unspecified).
The codes also require seventh characters that go at the end of the code to denote the episode of care, says Kristi Stanton, RHIT, CCS, CPC, CIRCC, AHIMA-approved ICD-10-CM/PCS trainer, AHIMA ICD-10 ambassador, and senior consultant with the Haugen Consulting Group in Denver.
"First of all, these must be in the seventh character position, and some of the codes that we have only have four or five characters, so we use an X as a placeholder," Stanton says. "Whenever I go back and look at my initial training notebook, I have to say that probably the most glaringly obvious mistake that I made was leaving out my placeholders."
For sprains, strains, and dislocations, coders will have three seventh character options:
- A, initial encounter. This means that the patient is receiving active treatment for an injury. This could be surgery. It could be an emergency department encounter. It could be evaluation and treatment by a new physician. "As long as the patient is receiving active treatment, they get an A," Stanton says.
- D, subsequent encounter. This means the patient is now in the healing phase. This character includes aftercare and follow-up visits following injury treatment.
- S, sequela. This seventh character is used for late effects, which are now referred to as sequela under ICD-10-CM—a simple terminology change. "Whatever was a late effect in ICD-9 is now a sequela in ICD-10," Stanton says. An example of this character's use would be for a patient who has a condition such as a scar contracture caused by a burn. "You would code the burn again, but you would apply this S code. That's how we know that it's not an acute treatment or an acute condition that is receiving active treatment, but it is something that occurred in the past and now has caused some late effects."
For example, a sprain of the ligaments of the cervical spine is reported with ICD-10-CM code S13.4-. Because the base code is only four characters long, coders need to add two X's to the code. For a subsequent encounter for a sprain of the ligaments of the cervical spine, coders would report S13.4XXD.
Acute and chronic injuries
ICD-10-CM separates acute and chronic injuries into different chapters. Chapter 13 includes all of the diseases of the musculoskeletal system and connective tissue. These codes begin with M.
"If you want to compare this to ICD-9, these are the 700 [series] codes in ICD-9 for the back pain and the arthritis and those degenerative orthopedic conditions," Stanton says. "These are going to tend to be your chronic and recurrent conditions, as opposed to those found in chapter 19, the injury and poisoning codes, and it also includes those certain other consequences of external causes."
The ICD-10-CM chapter 19 S and T codes are the equivalent of the 800 and 900 series codes in ICD-9-CM. The S codes are injuries classified by site and then by type, and the T codes are injuries involving multiple and unspecified regions. "Again, these are going to be your acute conditions and traumatic injuries as opposed to those that may be more chronic," Stanton says.
Coders will report acute dislocation of the knee using a code from subcategory S83.1- (subluxation and dislocation of knee). For an old dislocation of the knee, coders will use M23.8X- (other internal derangements of knee).
ICD-10-CM also has a new guideline for default codes that applies to chronic and acute injuries, says Stanton.
Default codes (I.A.18.):
A code listed next to a main term in the ICD-10-CM Alphabetic Index is referred to as a default code. The default code represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition. If a condition is documented in a medical record (for example, appendicitis) without any additional information, such as acute or chronic, the default code should be assigned.
A better example for orthopedics is a torn meniscus. "If you look in the index under 'tear, meniscus,' it immediately gives us an S code," Stanton says. "If you're not familiar with the S versus the M codes, this is like an 800 code in ICD-9." The S code represents a traumatic injury, but meniscal tears are not always necessarily traumatic, and they're not necessarily acute. This could be a patient who has an old tear. The old tear is indented in the ICD-10-CM Alphabetic Index, and coders are directed to see "derangement, knee, meniscus, due to old tear."
"The point that I really want to make with this default code is we really cannot go shopping in the ICD-10 index, for lack of a better term," Stanton says. "We really need to have the documentation to back up that we have an old tear. Otherwise, we have to go with our default code because ICD-10 does make some assumptions for us that most of the time a meniscus tear will be acute. If we don't have further documentation, it will automatically send us to that traumatic injury."
The ICD-10-CM coding guidelines state that if coders cannot determine whether a condition is acute or chronic from the documentation in the record, they should query the physician.
When looking up a meniscus tear in the ICD-10-CM Alphabetic Index, coders will find the following choices:
- Meniscus (knee) (current injury) S83.209
- Medial
- bucket-handle S83.21-
- complex S83.23-
- peripheral S83.22-
- specified type NEC S83.24-
- old—see Derangement, knee, meniscus, due to old tear
Under derangement, knee (recurrent), coders will find:
- Meniscus
- due to old tear or injury M23.20-
- Lateral M23.20-
- Anterior horn M23.24-
- Posterior horn M23.25-
- Specified NEC M23.26-
- Medial M23.20-
- Anterior horn M23.21-
- Posterior horn M23.22-
- Specified NEC M23.23-
ICD-10-CM really allows coders to drill down into the type of meniscus tear for both acute and chronic injuries, Stanton says.
Sprains and strains
A sprain is a stretch and/or tear of a ligament, the fibrous band of connective tissue that joins the end of one bone with another. Ligaments stabilize and support the body's joints. For example, ligaments in the knee connect the upper leg with the lower leg, enabling people to walk and run.
Sprains do not involve a dislocation or fracture. "If you also have a dislocation or fracture of that area where you've got a sprain, you're going to capture the dislocation and fracture and not the sprain," says Kim Carr, RHIT, CCS, CDIP, CCDS, AHIMA-approved ICD-10-CM/PCS trainer, AHIMA ICD-10-CM/PCS ambassador, and director of clinical documentation at HRS in Baltimore.
Sprains are often referred to as tears. They result from some type of abnormal or excessive force of the joint, such as twisting. In ICD-10-CM, coders will now be able to report sprains by severity:
- Grade 1, mild. Ligaments are stretched but not torn.
- Grade 2, moderate. Ligaments are partially torn, and there may be some loss of function.
- Grade 3, severe. Ligaments are completely torn/ruptured.
A strain is an injury of a muscle and/or tendon. Tendons are fibrous cords of tissue that attach muscles to bone. Strains typically result from strenuous activity. They're often referred to as a pulled muscle. Like sprains, these can range from mild to severe.
"A lot of times, you have some small vessel injuries," Carr says. "Small blood vessels are involved and can be damaged, and that's where the bruising at that site comes from."
In ICD-9-CM, coders report sprains and strains within the same category. The codes are specific only to site, but they do not differentiate between a sprain and a strain, Carr says. "In ICD-10, it's a little different. Sprains and strains are reported with different categories. Sprains are categorized with dislocations, and strains are categorized with other injuries."
The codes are specific to the:
- Type of injury
- Site
- Laterality
- Episode of care
ICD-10-CM includes a subcategory for traumatic ruptures to the ligaments of the forearm, wrist, and hands. These injuries may also be referred to as a grade 3 sprain. For all other sites, traumatic ruptures of a ligament are going to be captured with a sprain, Carr says.
If there is an open wound associated with a sprain, strain, or ruptured ligament, the open wound is reported with an additional code in ICD-10-CM.
"In ICD-9-CM, we have a combination code for an open wound with tendons/ligaments involved," Carr says. "We don't have that combo code anymore in ICD-10-CM. You have to actually capture two codes if you've got a sprain or a strain with an open wound."
In order to code a sprain or a strain, first of all, coders must identify the injury, Carr says. Is it a sprain? Is it a strain? Is it a traumatic rupture of a ligament of the forearm, wrist, or hand only?
If it is a sprain or strain, coders need to know:
- Site of the sprain
- Laterality
- Episode of care
"If it's a traumatic rupture of a ligament, you need to know the general region of that traumatic rupture of the forearm, wrist, hand, or finger, and then identify the site in the forearm, wrist, and hand, the laterality, and last but not least would be the episode of care," Carr says.
Dislocations
A dislocation is a joint injury that involves movement of joint-forming bones into abnormal or disarranged positions. A complete dislocation is a disruption or loss of contact between the articular surfaces of the involved bone. Some dislocations can be further differentiated by the amount of displacement and the direction of that displacement, such as:
- Anterior
- Posterior
- Inferior
- Other direction
A patient may also suffer an incomplete or partial dislocation. ICD-10-CM refers to these dislocations as subluxations, and they are characterized by an altered relationship between bones without loss of contact between the articular surfaces. "These can often be referred to as a sprain or separation of a joint," says Carr.
To code dislocations, coders must first determine the type of injury.
- Was it a subluxation or a dislocation?
- Was it traumatic, recurrent, pathological, or congenital?
- Where was the site of this dislocation?
- Which side of the body is involved?
- What is the episode of care?
For example, a physician documents a dislocation of the ankle joint. In ICD-10-CM, coders have three code choices:
- S93.04-, dislocation of right ankle joint
- S93.05-, dislocation of left ankle joint
- S93.06-, dislocation of unspecified ankle joint
All three codes require an X placeholder and a seventh character to denote the encounter.
For dislocations of six particular joints, coders also need to know the direction of the dislocation. Those joints include:
- Acromioclavicle
- Elbow
- Hip
- Proximal tibia
- Radial head on the humerus
"If you have a dislocation of those joints, you also are going to have to know what direction the displacement was," Carr says. "Was it anterior, posterior, inferior, or was it in a different direction or other direction?"
Now compare coding for a dislocation of the anterior elbow in ICD-9-CM and ICD-10-CM.
In ICD-9-CM, coders use a combination code to denote whether the patient suffered an open wound in association with the dislocation. That information is captured in the fourth character: 0 for a closed dislocation and 1 for an open dislocation, Carr says.
For an open anterior dislocation of the elbow, report ICD-9-CM code 832.11. See Coding Clinic, Fourth Quarter 2012, for more information.
In ICD-10-CM, coders will need to report two codes. "There's no longer a combo code that includes both the dislocation and the open and closed status, so you're going to have to also capture an open wound of the area where that dislocation is," Carr says.
In ICD-10-CM, coders would report the following codes:
- S53.114A, anterior dislocation of right ulnohumeral joint, initial encounter
- S51.001A, unspecified open wound, right elbow, initial encounter
Some dislocation codes identify the site of the dislocation much more specifically than the ICD-9-CM codes. Consider a dislocation of the toe. In ICD-9-CM, coders have two choices:
- 838.09, closed dislocation, toe(s)
- 838.19, open dislocation, toe(s)
ICD-10-CM, however, includes codes for:
- Right great toe
- Right lesser toe(s)
- Left great toe
- Left lesser toe(s)
ICD-10-CM further breaks out the individual joints in the toes, including:
- Interphalangeal joint
- Metatarsophalangeal joint
These codes all require a seventh character to denote the encounter. Coders will also need to report an additional code for any open wounds.
Editor’s note: This article was originally published in the October issue of Briefings on Coding Compliance Strategies.Email your questions to Senior Managing Editor Michelle A. Leppert, CPC, at mleppert@hcpro.com.