ICD-10 Tips for Orthopedists
Clinical Documentation Tips for Orthopedists
Specifying anatomical location and laterality required by ICD-10 is easier than you think.
This detail reflects how physicians and clinicians communicate and to what they pay attention. It is a matter of ensuring the information is captured in your documentation.
In ICD-10-CM, there are three main categories of changes:
- Definition Changes
- Terminology Differences
- Increased Specificity
For orthopedics the focus is on increased specificity. Over 1/3 of the expansion of ICD-10 codes is due to the addition of
laterality (left, right, or bilateral). Physicians and other clinicians likely already note laterality when evaluating the clinically
When documenting fractures, include the following parameters:
- Type e.g. Open, closed, pathological, neoplastic disease, stress
- Pattern e.g. Comminuted, oblique, segmental, spiral, transverse
- Etiology to document in the external cause codes
- Encounter of care e.g. Initial, subsequent, sequelae
- Healing status, if subsequent encounter e.g. Normal healing, delayed healing, nonunion, malunion
- Localization e.g. Shaft, head, neck, distal, proximal, styloid
- Displacement e.g. Displaced, non displaced
- Classification e.g. Gustilo-Anderson, Salter-Harris
- Any complications, whether acute or delayed e.g. Direct result of trauma sustained
In addition, depending on the circumstances, it may be necessary to document intra-articular or extra-articular involvement.
For certain conditions, the bone may be affected at the proximal or distal end. Though the portion of the bone affected may be at the joint at either end, the site designation will be the bone, not the joint.
ICD-10 Code Examples
S52.521A Torus fracture of lower end of right radius, initial encounter for closed fracture
S52.521D Torus fracture of lower end of right radius, subsequent encounter for fracture with routine healing
S42.021K Displaced fracture of the shaft of right clavicle, subsequent for fracture with nonunion
In ICD-10-CM, there are specific codes for primary and secondary arthritis. Within the secondary arthritis codes there are specific codes for post-traumatic osteoarthritis and other secondary osteoarthritis. For secondary osteoarthritis of the hip there is also a code for dysplastic osteoarthritis.
Arthritis codes in ICD-10-CM is both similar and different than ICD-9-CM. For example, currently, in ICD-9, osteoarthritis can be described as degenerative, hypertrophic, or secondary to other factors, and the type as generalized or localized. ICD-10 provides more options for the coding osteoarthritis related encounters, including:
- Generalized forms of osteoarthritis or arthritis where multiple joints are involved.
- Localized forms of osteoarthritis with more specificity that includes primary versus secondary types, subtypes, laterality, and joint involvement.
Indicate the type, location, and specific bones and joints (multiple sites if applicable) involved in the disease. In addition, describe any related underlying diseases or conditions.
ICD-10 Code Examples
M19.041 Primary osteoarthritis right hand
M19.241 Secondary osteoarthritis, right hand
M05.432 Rheumatoid myopathy with rheumatoid arthritis of left wrist
ICD-9 used separate “E codes” to record external causes of injury. ICD-10 better incorporates these codes and expands sections on poisonings and toxins.
When documenting injuries, include the following:
- Episode of Care e.g. Initial, subsequent, sequelae
- Injury site Be as specific as possible
- Etiology How was the injury sustained (e.g. sports, motor vehicle crash, pedestrian, slip and fall, environmental exposure, etc.)?
- Place of Occurrence e.g. School, work, etc.
Initial encounters may also require, where appropriate:
- Intent e.g. Unintentional or accidental, self-harm, etc.
- Status e.g. Civilian, military, etc.
ICD-10 Code Examples
A left knee strain injury that occurred on a private recreational playground when a child landed incorrectly from a trampoline:
- Injury: S86.812A, Strain of other muscle(s) and tendon(s) at lower leg level, left leg, initial encounter
- External cause: W09.8xxA, Fall on or from other playground equipment, initial encounter
- Place of occurrence: Y92.838, Other recreation area as the place of occurrence of the external cause
- Activity: Y93.44, Activities involving rhythmic movement, trampoline jumping
On October 31st, Carol Patient was seen in the ER for shoulder pain and X-rays indicated there was a fracture of the right clavicle, shaft. She returned three months later with complaints of continuing pain. X-rays indicated a nonunion. The second encounter for the right clavicle fracture is coded as S42.021K, Displaced fracture of the shaft of right clavicle, subsequent for fracture with nonunion.