Interventional Pain ICD-10 Documentation Guidance

[Pages:4]Interventional Pain ICD-10 Documentation Guidance

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Interventional Pain ICD-10 CM Assessment

The following information was abstracted from a blinded sampling of various Interventional Pain services.

The diagnosis code and description on the left side is the ICD-9 code utilized and the columns indicated by code, as well as the Documentation Suggestions is the information needed to accurately and specifically code for ICD-10.

Lastly, this information contains a description of the column language to clarify the meaning used within the nomenclature of the ICD-10 code set.

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ICD-10-CM Documentation Assessment ? Interventional Pain

ICD-9

Diagnosis

ICD-9 Description

Laterality

Episode Care

of

Acute/ Chronic

Anatomical Site Specificity

Documentation Issues

Patient History

Injury How / What

Trimester

053.19 Herpes zoster with other complications

X

X

X

Diabetes with neurological

250.61

manifestations, type I [juvenile type],

X

not stated as uncontrolled

337.22

RSD of the lower limb

X

X

X

349.2 353.8

Disorders of meninges, not elsewhere classified

Unspecified nerve root and plexus disorder

X

X

X

X

X

X

X

X

682.9

Cellulitis and abscess; unspecified site X

X

X

X

X

714.9

Unspecified inflammatory polyarthropathies

X

Osteoarthrosis, localized, not specified

715.35

whether primary or secondary, pelvic

X

region and thigh

X

X

X

X

716.98

Arthropathy, unspecified, other specified sites

X

X

X

ICD-10 Documentation Suggestions

B02.29

?

Include other complications ? radiculopathy/polyneuropathy

E10.40

G90.529

? ?

G96.12G9619

?

Limbs affected; Type I or Idiopathic

Congenital/Tuberculous

G54.8 ? Specific nerve

L03.90 ? L03.91

?

Bug and cause

M06.4 ? Cause of inflammation

M16.9 M12.9

? Specificity of location of arthrosis

? Specificity of location of arthrosis

719.41

Shoulder pain

X

721.3

Lumbosacral spondylosis without myelopathy

X

722.10

Lumbar intervertebral disc without myelopathy

X

723.4

Brachia neuritis or radiculitis NOS

X

724.02

Lumbar region, with neurogenic claudication

X

729.1

Myalgia and myositis, unspecified

X

V58.83

Encounter for therapeutic drug monitoring

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

M25.519

? ?

M47.817 ?

M47.898

May need

? ?

Clarificatio

n

M51.26 ? ?

M51.27 ?

M54.12 ? ?

M54.13 ?

M48.06

? ?

M60.9- ?

M79.7 ?

Z51.81

? ?

L/R; Cause

Multiple codes to cross walk; Radiculopathy/myelopathy

Areas involved Cause if known Areas involved Cause if known Many codes in crosswalk; Include other processes Type of myalgia; Anatomic sites involved Include drug specifics ? Requires additional code

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ICD-10 Category Requirements

Laterality: Include Left, Right, Bilateral, Unilateral

Episode of Care: Identify initial, subsequent or sequalae visit. For Fractures, include whether fracture

is open/closed, whether healing process is routine or with complications such as delayed healing, nonunion, malunion. Gustilo Open Fracture classifications include designation of Type I, Type II, Type III

Acute/Chronic: Identify acute/chronic nature. More specificity for Postoperative,

neoplasm related, Post thoracotomy

Anatomical Site Specificity: Identify specific area:

Chest: Wall, Limb: Specific area on the limb Abdominal

Patient History: Medical history that provides additional context.

Injury How / What: Include how the injury happened, and what activity the

patient was doing when the injury occurred.

Pregnancy: Trimester of pregnancy or identification of specific fetus. Other:

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