ICD-10: Clinical Concepts For Orthopedics

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ICD-10Clinical Conceptsfor OrthopedicsICD-10 Clinical Concepts SeriesCommon CodesClinical Documentation TipsClinical ScenariosICD-10 Common Codes for Orthopedics is a feature ofRoad to 10, a CMS online tool built with physician input.With Road to 10, you can:lBuild an ICD-10 action plan customizedfor your practicel Useinteractive case studies to see howyour coding selections compare with yourpeers’ codinglAccess quick references from CMS andmedical and trade associationslView in-depth webcasts for and bymedical professionalsTo get on the Road to 10 and find out more about ICD-10, visit:cms.gov/ICD10roadto10.orgICD-10 Compliance Date: October 1, 2015Official CMS Industry Resources for the ICD-10 Transitionwww.cms.gov/ICD101

Table Of ContentsCommon Codes Cervical Spine Disorders andDisplacement Selected ShoulderConditions Neck and Back Pain Spinal Stenosis of theLumbar Region Osteoarthritis ofthe Hip Osteoarthritis of the Knee Radiculopathy (Primary) Rheumatoid Arthritis Selected Sprains – RotatorCuff, Cruciate Ligament,and Ankle Thoracic, Thoracolumbar,and LumbosacralIntervertebral Disc DisordersClinical Documentation Tips Fractures Arthritis InjuriesClinical Scenarios Scenario 1: FractureFollow-Up Visit Scenario: CervicalDisc Disease Scenario 2: ShoulderROM Office Visit Scenario: Struck by Car Scenario 3: Tear of MedialMeniscus With AnteriorCruciate Ligament Injury Scenario: Fracture

Common CodesICD-10 Compliance Date: October 1, 2015Cervical Spine Disorders and Displacement(ICD-9-CM 722.0, 722.4, 722.71, 722.91, M50.93Cervical disc disorder with myelopathy, unspecified cervical regionCervical disc disorder with myelopathy, occipito-atlanto-axial regionCervical disc disorder with myelopathy, mid-cervical regionCervical disc disorder with myelopathy, cervicothoracic regionCervical disc disorder with radiculopathy, unspecified cervical regionCervical disc disorder with radiculopathy, occipito-atlanto-axial regionCervical disc disorder with radiculopathy, mid-cervical regionCervical disc disorder with radiculopathy, cervicothoracic regionOther cervical disc displacement, unspecified cervical regionOther cervical disc displacement, occipito-atlanto-axial regionOther cervical disc displacement, mid-cervical regionOther cervical disc displacement, cervicothoracic regionOther cervical disc degeneration, unspecified cervical regionOther cervical disc degeneration, occipito-atlanto-axial regionOther cervical disc degeneration, mid-cervical regionOther cervical disc degeneration, cervicothoracic regionOther cervical disc disorders, unspecified cervical regionOther cervical disc disorders, occipito-atlanto-axial regionOther cervical disc disorders, mid-cervical regionOther cervical disc disorders, cervicothoracic regionCervical disc disorder, unspecified, unspecified cervical regionCervical disc disorder, unspecified, occipito-atlanto-axial regionCervical disc disorder, unspecified, mid-cervical regionCervical disc disorder, unspecified, cervicothoracic region*Codes with a greater degree of specificity should be considered first.3

Neck and Back Pain (ICD-9-CM 723.1, 724.1, 724.2, 724.3, 54.5M54.6M54.89M54.9*CervicalgiaSciatica, unspecified sideSciatica, right sideSciatica, left sideLumbago with sciatica, unspecified sideLumbago with sciatica, right sideLumbago with sciatica, left sideLow back painPain in thoracic spineOther dorsalgiaDorsalgia, unspecified*Codes with a greater degree of specificity should be considered first.Osteoarthritis of the Hip (ICD-9-CM 715.15, 715.25, 715.35, eral primary osteoarthritis of hipUnilateral primary osteoarthritis, unspecified hipUnilateral primary osteoarthritis, right hipUnilateral primary osteoarthritis, left hipBilateral osteoarthritis resulting from hip dysplasiaUnilateral osteoarthritis resulting from hip dysplasia, unspecified hipUnilateral osteoarthritis resulting from hip dysplasia, right hipUnilateral osteoarthritis resulting from hip dysplasia, left hipBilateral post-traumatic osteoarthritis of hipUnilateral post-traumatic osteoarthritis, unspecified hipUnilateral post-traumatic osteoarthritis, right hipUnilateral post-traumatic osteoarthritis, left hipOther bilateral secondary osteoarthritis of hipOther unilateral secondary osteoarthritis of hipOsteoarthritis of hip, unspecified*Codes with a greater degree of specificity should be considered first.4

Osteoarthritis of the Knee (ICD-9-CM 715.16, 715.26, 715.36, 17.32M17.4M17.5M17.9*Bilateral primary osteoarthritis of kneeUnilateral primary osteoarthritis, unspecified kneeUnilateral primary osteoarthritis, right kneeUnilateral primary osteoarthritis, left kneeBilateral post-traumatic osteoarthritis of kneeUnilateral post-traumatic osteoarthritis, unspecified kneeUnilateral post-traumatic osteoarthritis, right kneeUnilateral post-traumatic osteoarthritis, left kneeOther bilateral secondary osteoarthritis of kneeOther unilateral secondary osteoarthritis of kneeOsteoarthritis of knee, unspecified*Codes with a greater degree of specificity should be considered first.Radiculopathy (Primary) (ICD-9-CM 723.4, 724.3, 724.4, 54.17M54.18M54.30*M54.31M54.32Radiculopathy, site unspecifiedRadiculopathy, occipito-atlanto-axial regionRadiculopathy, cervical regionRadiculopathy, cervicothoracic regionRadiculopathy, thoracic regionRadiculopathy, thoracolumbar regionRadiculopathy, lumbar regionRadiculopathy, lumbosacral regionRadiculopathy, sacral and sacrococcygeal regionSciatica, unspecified sideSciatica, right sideSciatica, left side*Codes with a greater degree of specificity should be considered first.5

Rheumatoid Arthritis (ICD-9-CM 714.0, 714.2)Excludes Combination Codes that Include Neuropathy, Bursitis andNodule Codes, and the Codes that Indicate “Unspecified 651M05.652M05.659*M05.661Rheumatoid arthritis of right shoulder with involvement of otherorgans and systemsRheumatoid arthritis of left shoulder with involvement of otherorgans and systemsRheumatoid arthritis of unspecified shoulder with involvementof other organs and systemsRheumatoid arthritis of right elbow with involvement of otherorgans and systemsRheumatoid arthritis of left elbow with involvement of otherorgans and systemsRheumatoid arthritis of unspecified elbow with involvementof other organs and systemsRheumatoid arthritis of right wrist with involvement of otherorgans and systemsRheumatoid arthritis of left wrist with involvement of other organsand systemsRheumatoid arthritis of unspecified wrist with involvement of otherorgans and systemsRheumatoid arthritis of right hand with involvement of other organsand systemsRheumatoid arthritis of left hand with involvement of other organsand systemsRheumatoid arthritis of unspecified hand with involvement of otherorgans and systemsRheumatoid arthritis of right hip with involvement of other organsand systemsRheumatoid arthritis of left hip with involvement of other organsand systemsRheumatoid arthritis of unspecified hip with involvement of otherorgans and systemsRheumatoid arthritis of right knee with involvement of other organsand systems*Codes with a greater degree of specificity should be considered first.6

Rheumatoid Arthritis (ICD-9-CM 714.0, 714.2)Excludes Combination Codes that Include Neuropathy, Bursitis andNodule Codes, and the Codes that Indicate “Unspecified 5.729*M05.731M05.732M05.739*M05.741Rheumatoid arthritis of left knee with involvement of other organsand systemsRheumatoid arthritis of unspecified knee with involvement of otherorgans and systemsRheumatoid arthritis of right ankle and foot with involvement ofother organs and systemsRheumatoid arthritis of left ankle and foot with involvement ofother organs and systemsRheumatoid arthritis of unspecified ankle and foot with involvementof other organs and systemsRheumatoid arthritis of multiple sites with involvement of otherorgans and systemsRheumatoid arthritis with rheumatoid factor of right shoulder withoutorgan or systems involvementRheumatoid arthritis with rheumatoid factor of left shoulder withoutorgan or systems involvementRheumatoid arthritis with rheumatoid factor of unspecified shoulderwithout organ or systems involvementRheumatoid arthritis with rheumatoid factor of right elbow withoutorgan or systems involvementRheumatoid arthritis with rheumatoid factor of left elbow withoutorgan or systems involvementRheumatoid arthritis with rheumatoid factor of unspecified elbowwithout organ or systems involvementRheumatoid arthritis with rheumatoid factor of right wrist withoutorgan or systems involvementRheumatoid arthritis with rheumatoid factor of left wrist without organor systems involvementRheumatoid arthritis with rheumatoid factor of unspecified wristwithout organ or systems involvementRheumatoid arthritis with rheumatoid factor of right hand withoutorgan or systems involvement*Codes with a greater degree of specificity should be considered first.7

Rheumatoid Arthritis (ICD-9-CM 714.0, 714.2)Excludes Combination Codes that Include Neuropathy, Bursitis andNodule Codes, and the Codes that Indicate “Unspecified M05.831M05.832Rheumatoid arthritis with rheumatoid factor of left hand without organor systems involvementRheumatoid arthritis with rheumatoid factor of unspecified handwithout organ or systems involvementRheumatoid arthritis with rheumatoid factor of right hip without organor systems involvementRheumatoid arthritis with rheumatoid factor of left hip without organor systems involvementRheumatoid arthritis with rheumatoid factor of unspecified hip withoutorgan or systems involvementRheumatoid arthritis with rheumatoid factor of right knee without organor systems involvementRheumatoid arthritis with rheumatoid factor of left knee without organor systems involvementRheumatoid arthritis with rheumatoid factor of unspecified knee withoutorgan or systems involvementRheumatoid arthritis with rheumatoid factor of right ankle and foot withoutorgan or systems involvementRheumatoid arthritis with rheumatoid factor of left ankle and foot withoutorgan or systems involvementRheumatoid arthritis with rheumatoid factor of unspecified ankle and footwithout organ or systems involvementRheumatoid arthritis with rheumatoid factor of multiple sites without organor systems involvementOther rheumatoid arthritis with rheumatoid factor of right shoulderOther rheumatoid arthritis with rheumatoid factor of left shoulderOther rheumatoid arthritis with rheumatoid factor of unspecified shoulderOther rheumatoid arthritis with rheumatoid factor of right elbowOther rheumatoid arthritis with rheumatoid factor of left elbowOther rheumatoid arthritis with rheumatoid factor of unspecified elbowOther rheumatoid arthritis with rheumatoid factor of right wristOther rheumatoid arthritis with rheumatoid factor of left wrist*Codes with a greater degree of specificity should be considered first.8

Rheumatoid Arthritis (ICD-9-CM 714.0, 714.2)Excludes Combination Codes that Include Neuropathy, Bursitis andNodule Codes, and the Codes that Indicate “Unspecified 1Other rheumatoid arthritis with rheumatoid factor of unspecified wristOther rheumatoid arthritis with rheumatoid factor of right handOther rheumatoid arthritis with rheumatoid factor of left handOther rheumatoid arthritis with rheumatoid factor of unspecified handOther rheumatoid arthritis with rheumatoid factor of right hipOther rheumatoid arthritis with rheumatoid factor of left hipOther rheumatoid arthritis with rheumatoid factor of unspecified hipOther rheumatoid arthritis with rheumatoid factor of right kneeOther rheumatoid arthritis with rheumatoid factor of left kneeOther rheumatoid arthritis with rheumatoid factor of unspecified kneeOther rheumatoid arthritis with rheumatoid factor of right ankle and footOther rheumatoid arthritis with rheumatoid factor of left ankle and footOther rheumatoid arthritis with rheumatoid factor of unspecifiedankle and footOther rheumatoid arthritis with rheumatoid factor of multiple sitesRheumatoid arthritis with rheumatoid factor, unspecifiedRheumatoid arthritis without rheumatoid factor, unspecified siteRheumatoid arthritis without rheumatoid factor, right shoulderRheumatoid arthritis without rheumatoid factor, left shoulderRheumatoid arthritis without rheumatoid factor, unspecified shoulderRheumatoid arthritis without rheumatoid factor, right elbowRheumatoid arthritis without rheumatoid factor, left elbowRheumatoid arthritis without rheumatoid factor, unspecified elbowRheumatoid arthritis without rheumatoid factor, right wristRheumatoid arthritis without rheumatoid factor, left wristRheumatoid arthritis without rheumatoid factor, unspecified wristRheumatoid arthritis without rheumatoid factor, right handRheumatoid arthritis without rheumatoid factor, left handRheumatoid arthritis without rheumatoid factor, unspecified handRheumatoid arthritis without rheumatoid factor, right hipRheumatoid arthritis without rheumatoid factor, left hipRheumatoid arthritis without rheumatoid factor, unspecified hipRheumatoid arthritis without rheumatoid factor, right knee*Codes with a greater degree of specificity should be considered first.9

Rheumatoid Arthritis (ICD-9-CM 714.0, 714.2)Excludes Combination Codes that Include Neuropathy, Bursitis andNodule Codes, and the Codes that Indicate “Unspecified umatoid arthritis without rheumatoid factor, left kneeRheumatoid arthritis without rheumatoid factor, unspecified kneeRheumatoid arthritis without rheumatoid factor, right ankle and footRheumatoid arthritis without rheumatoid factor, left ankle and footRheumatoid arthritis without rheumatoid factor, unspecified ankle and footRheumatoid arthritis without rheumatoid factor, vertebraeRheumatoid arthritis without rheumatoid factor, multiple sitesOther specified rheumatoid arthritis, unspecified siteOther specified rheumatoid arthritis, right shoulderOther specified rheumatoid arthritis, left shoulderOther specified rheumatoid arthritis, unspecified shoulderOther specified rheumatoid arthritis, right elbowOther specified rheumatoid arthritis, left elbowOther specified rheumatoid arthritis, unspecified elbowOther specified rheumatoid arthritis, right wristOther specified rheumatoid arthritis, left wristOther specified rheumatoid arthritis, unspecified wristOther specified rheumatoid arthritis, right handOther specified rheumatoid arthritis, left handOther specified rheumatoid arthritis, unspecified handOther specified rheumatoid arthritis, right hipOther specified rheumatoid arthritis, left hipOther specified rheumatoid arthritis, unspecified hipOther specified rheumatoid arthritis, right kneeOther specified rheumatoid arthritis, left kneeOther specified rheumatoid arthritis, unspecified kneeOther specified rheumatoid arthritis, right ankle and footOther specified rheumatoid arthritis, left ankle and footOther specified rheumatoid arthritis, unspecified ankle and footOther specified rheumatoid arthritis, vertebraeOther specified rheumatoid arthritis, multiple sitesRheumatoid arthritis, unspecified*Codes with a greater degree of specificity should be considered first.10

Selected Shoulder Conditions (ICD-9-CM 726.0, 726.10 to 726.19range, 726.2, 1M75.22M75.30*M75.31M75.32M75.40*M75.41Spontaneous rupture of extensor tendons, right shoulderSpontaneous rupture of extensor tendons, left shoulderSpontaneous rupture of extensor tendons, unspecified shoulderSpontaneous rupture of other tendons, right shoulderSpontaneous rupture of other tendons, left shoulderSpontaneous rupture of other tendons, unspecified shoulderAdhesive capsulitis of unspecified shoulderAdhesive capsulitis of right shoulderAdhesive capsulitis of left shoulderUnspecified rotator cuff tear or rupture of unspecified shoulder, notspecified as traumaticUnspecified rotator cuff tear or rupture of right shoulder, not specifiedas traumaticUnspecified rotator cuff tear or rupture of left shoulder, not specifiedas traumaticIncomplete rotator cuff tear or rupture of unspecified shoulder, notspecified as traumaticIncomplete rotator cuff tear or rupture of right shoulder, not specifiedas traumaticIncomplete rotator cuff tear or rupture of left shoulder, not specifiedas traumaticComplete rotator cuff tear or rupture of unspecified shoulder, not specifiedas traumaticComplete rotator cuff tear or rupture of right shoulder, not specifiedas traumaticComplete rotator cuff tear or rupture of left shoulder, not specifiedas traumaticBicipital tendinitis, unspecified shoulderBicipital tendinitis, right shoulderBicipital tendinitis, left shoulderCalcific tendinitis of unspecified shoulderCalcific tendinitis of right shoulderCalcific tendinitis of left shoulderImpingement syndrome of unspecified shoulderImpingement syndrome of right shoulder*Codes with a greater degree of specificity should be considered first.11

Selected Shoulder Conditions (ICD-9-CM 726.0, 726.10 to 726.19range, 726.2, 727.61) 75.82M75.90*M75.91*M75.92*Impingement syndrome of left shoulderBursitis of unspecified shoulderBursitis of right shoulderBursitis of left shoulderOther shoulder lesions, unspecified shoulderOther shoulder lesions, right shoulderOther shoulder lesions, left shoulderShoulder lesion, unspecified, unspecified shoulderShoulder lesion, unspecified, right shoulderShoulder lesion, unspecified, left shoulder*Codes with a greater degree of specificity should be considered first.Spinal Stenosis of the Lumbar Region (ICD-9-CM 99.73Spinal stenosis, lumbar regionSpinal stenosis, lumbosacral regionSubluxation stenosis of neural canal of lumbar regionOsseous stenosis of neural canal of lumbar regionConnective tissue stenosis of neural canal of lumbar regionIntervertebral disc stenosis of neural canal of lumbar regionOsseous and subluxation stenosis of intervertebral foramina oflumbar regionConnective tissue and disc stenosis of intervertebral foramina oflumbar region*Codes with a greater degree of specificity should be considered first.12

Selected Sprains – Rotator Cuff, Cruciate Ligament, and Ankle(ICD-9-CM 840.4, 844.0, 844.1, 844.2, 844.8, 845.01, 845.00 to845.09 range, 905.7, 521DSprain of right rotator cuff capsule, initial encounterSprain of right rotator cuff capsule, subsequent encounterSprain of right rotator cuff capsule, seq

ICD-10 Clinical Concepts Series ICD-10 Common Codes for Orthopedics is a feature of . Road to 10, a CMS online tool built with physician input. ICD-10. With Road to 10, you can: l. Build an ICD-10 action plan customized for your practice. l Use interactive case studies to see how your coding selections compare with your peers’ coding. lFile Size: 449KB

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