November 3, 2014

Clinical Documentation Improvement by Service –Musculoskeletal Diseases/Orthopedic Surgery


EDITOR’S NOTE: This is the third article is the continuation of a series of articles on clinical documentation improvement by clinical service.   

Musculoskeletal disease treatment and orthopedic surgery: Coding of these services will be challenging under ICD-10-CM/PCS. What are the necessary documentation changes? Let’s take a look at some examples.


Osteoarthritis: The documentation of osteoarthritis does not change significantly between the two classification systems. ICD-10-CM has the sub-classifications of secondary, primary, post-traumatic, and generalized, which is different from the “localized” and “generalized” classifications used in ICD-9-CM. The most obvious change between the two is that ICD-10-CM can identify laterality, which should impact claims editing. For example, X-rays performed on the right knee should have a diagnosis that identifies the right knee.

Complications of a Device: These can include mechanical issues and infections in both classification systems, but ICD-10-CM provides more specificity regarding the joint (laterality and anatomic site) with the complication. The complication type (loosening, pain, infection, prosthetic fracture, misalignment, etc.) should be clearly documented in the clinical information. Both classification systems have an instruction to add the joint replacement status code. For example, in ICD-9-CM, 996.44 represents the peri-prosthetic fracture around the prosthetic joint. If the knee joint is the problem area, then V43.65 would be an additional code. In ICD-10-CM, T84.842A represents the peri-prosthetic fracture around the right knee joint. In this case, the “use additional code to indicate the joint replacement status” is not needed. ICD-10-CM provides more information in one code regarding the laterality, the exact site, and the episode of care. In the previous example, while ICD-9-CM does give specific information regarding the type of complication, it never provides the laterality specificity.

Hip Fractures: In ICD-9-CM, coding of hip fractures provides some specifics regarding the site of the femoral fracture. Again, ICD-10-CM goes the extra mile here to provide information regarding the laterality. The episode of care information is coded using separate codes in ICD-9-CM, while ICD-10-CM relays the information in the seventh character. This feature enhances data analysis, as the reviewer can identify how many hip fractures have occurred previously and how many are in the acute phase, how many are in the healing phase, and if there are any complications. The seventh character is based on the Gustilo scale. ICD-9-CM has one code for malunion and one code for nonunion of fracture, while ICD-10-CM provides specificity regarding the specific bone and laterality for these complications. Hospital coders need some specifics regarding how an accident occurred and where it occurred, as some states have mandatory external cause reporting. This information can be found in the ED documentation or in the attending physician documentation.

Admission to Rehabilitation: In ICD-9-CM this diagnosis was used predominantly as the principal diagnosis for inpatient rehabilitation (V57.89). In ICD-10-CM, the guidelines have been amended to have the coder assign the code for the reason for the rehab as the principal diagnosis. The guideline change assists in the validation of medical necessity, and therefore will impact claims processing. Reasons for inpatient rehabilitation will become clearer, and perhaps this will assist in the further development of inpatient rehab facility prospective payment system. The MS-DRG for rehabilitation is triggered by the use of physical, occupational, and speech procedure codes (ICD-10-PCS), which is a change from the MS-DRG methodology. If you do not code these procedures in ICD-9-CM, you will see a MS-DRG shift when you convert your claims data. In preparation for ICD-10 implementation, facilities should discuss and make a decision on whether these procedure codes are needed.   The additional ICD-10-PCS codes may impact your productivity under ICD-10.

Total Hip/Knee Arthroplasty: There are three root operation choices when the procedure is arthroplasty – repair, replacement, and supplement. The coder must understand the goal of the procedure in order to choose the correct procedure code. The original replacement of the joint is coded with the root operation of replacement. If the physician is restoring the joint without any device, then the root operation is repair. If the surgeon is reinforcing the joint without removing the joint, then the root operation is supplement. It was so easy in ICD-9-CM Volume 3! The coder looked up arthroplasty and reviewed the subentries for the joint, and voila! – a code was provided. The coder may have needed to know if the replacement was complete or partial, but now the coder will need to know the type of device inserted, if the device is cemented/uncemented, and the specific body part (including laterality) in addition to the root operation. There is one potential issue that facilities can resolve prior to ICD-10 implementation, however. They should determine what documentation is the source of facts regarding the type of implant inserted – is it physician documentation or a device record? The documentation of this facility guideline can decrease coder questions after implementation when there is conflicting medical documentation.

Spinal Fusion: There are some differences with regard to documentation for spinal fusion. ICD-9-CM does not provide any options for the approach for this procedure, as it presumes open. ICD-10-PCS has percutaneous, percutaneous endoscopic, and open approaches in preparation for the medical advancement. The spinal column is divided into upper and lower joints in ICD-10-PCS, with the lumbar spine beginning the lower joints section. Lumbar joints are separated from lumbosacral joints, which are classified together in ICD-10-PCS. The documentation should be clear as to which spinal levels are involved in the spinal fusion, as each involved level will require a separate code. The type of device used in the fusion, if any, should be clearly documented as well, as it impacts on the device character in ICD-10-PCS as well as code assignment in ICD-9-CM. If bone graft material is used, the surgeon should document if the graft is autologous or non-autologous (bone bank/BMP). If an autologous graft is used, the harvesting should be documented as local or specify if a separate location was harvested (such as the iliac crest). In ICD-10-PCS, the separate harvesting would be coded in addition to the spinal fusion. The spinal column (anterior or posterior) affects the code assignment in both ICD-9-CM and ICD-10-PCS, so that documentation should be clear now. 

The exploration of musculoskeletal diseases/orthopedic surgery indicates that there are some changes regarding these matters, but more significant changes on the procedure side. Will we continue to see this trend as we explore other services? The next article in this series will focus on pulmonology/respiratory surgery.

Laurie Johnson, MS, RHIA, CPC-H, FAHIMA, AHIMA-Approved ICD-10-CM/PCS Trainer

Laurie M. Johnson, MS, RHIA, FAHIMA is currently a senior healthcare consultant for Revenue Cycle Solutions based in Pittsburgh, Pa. Laurie is an AHIMA approved ICD-10-CM/PCS Trainer. She has more than 35 years of experience in health information management and specializes in coding and related functions. She has been a featured speaker in over 40 conferences and will be speaking at 2017 AHIMA Coding Community Meeting in Los Angeles, Ca. Laurie has been a frequent guest on Talk Ten Tuesdays.