ICD-10-CM Coding Workbook for Orthopaedics - Medical Coding .Net

ICD-10-CM Coding Workbook for Orthopaedics

Specialty coding guidance for ICD-10-CM

2017

Contents

Introduction .............................................................................................................................................. 1

Overview of ICD-10 .............................................................................................................................................................................................. 1 Getting Ready for ICD-10 ................................................................................................................................................................................... 2 Using This ICD-10-CM Workbook ..................................................................................................................................................................... 2 Workbook Guidelines .......................................................................................................................................................................................... 3 Online Exams to Test Your ICD-10-CM Coding Skills ................................................................................................................................... 4 Summary ................................................................................................................................................................................................................ 4

Case Studies and Questions ...................................................................................................................... 5

Case Study #1--Total Knee Arthroplasty ....................................................................................................................................................... 5 Case Study #2--Radial Shaft Fracture ............................................................................................................................................................ 8 Case Study #3--Total Hip Arthroplasty ........................................................................................................................................................12 Case Study #4--Periprosthetic Fracture of Femur ....................................................................................................................................14 Case Study #5--Trigger Finger Release .......................................................................................................................................................17 Case Study #6--Digital Neuroma ..................................................................................................................................................................19 Case Study #7--Degenerative Joint Disease, Shoulder ...........................................................................................................................21 Case Study #8--ACL Tear ................................................................................................................................................................................23 Case Study #9--Radioulnar Synostosis ........................................................................................................................................................26 Case Study #10--Lunate Stress Fracture .....................................................................................................................................................28 Case Study #11--Fracture of Thumb ............................................................................................................................................................30 Case Study #12--Gangrene of Foot ..............................................................................................................................................................32 Case Study #13--Idiopathic Osteoporosis ..................................................................................................................................................35 Case Study #14--Rupture of Quadriceps Tendon .....................................................................................................................................37 Case Study #15--Wrist Laceration with Tendon Injury ...........................................................................................................................40 Case Study #16--Cervical Stenosis with Myelopathy ..............................................................................................................................43 Case Study #17--Rotator Cuff and Labral Tear of Shoulder ...................................................................................................................46 Case Study #18--ACL and Meniscus Injury, Knee .....................................................................................................................................49 Case Study #19--Meniscal Tear and Osteochondral Fracture, Knee ....................................................................................................51 Case Study #20--Degenerative Joint Disease, Shoulder .........................................................................................................................55 Case Study #21--Status Postlumbar Decompression with Osteoporosis ...........................................................................................57 Case Study #22--Osteoarthritis and Myofascial Pain Syndrome ..........................................................................................................62 Case Study #23--Left Foot Pain .....................................................................................................................................................................64 Case Study #24--Left Knee Pain ....................................................................................................................................................................67 Case Study #25--Humeral Fracture ..............................................................................................................................................................70 Case Study #26--Distal Fibular Fracture .....................................................................................................................................................73 Case Study #27--Planovalgus Feet with Myotonic Muscular Dystrophy ............................................................................................77 Case Study #28--Chronic Plantar Fasciitis ..................................................................................................................................................80 Case Study #29--Posterior Calf Pain ............................................................................................................................................................82 Case Study #30--Bunion and Hammer Toe ................................................................................................................................................85 Case Study #31--Erythema of the Knee ......................................................................................................................................................89 Case Study #32--Chronic Pain .......................................................................................................................................................................91 Case Study #33--Back and Shoulder Pain ...................................................................................................................................................94 Case Study #34--Carpal Tunnel Syndrome ................................................................................................................................................98 Case Study #35--Lytic Lesion of Cervical Vertebrae .............................................................................................................................. 100 Case Study #36--Patellar Tendon Rupture .............................................................................................................................................. 102 Case Study #37--Above-the-Knee Amputation ..................................................................................................................................... 105

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Contents

ICD-10-CM Coding Workbook for Orthopaedics

Case Study #38--Avascular Necrosis of Hip ............................................................................................................................................107 Case Study #39--Neck Pain Following MVA ............................................................................................................................................109 Case Study #40--Shoulder Osteoarthritis .................................................................................................................................................111 Case Study #41--Trauma to Finger ...........................................................................................................................................................114 Case Study #42--Open Tibia Fibula Fracture ...........................................................................................................................................117 Case Study #43--Transmetatarsal Amputation ......................................................................................................................................119 Case Study #44--Displaced Fifth Metacarpal Fracture ..........................................................................................................................121 Case Study #45--Follow-up for Tibial Plateau Fracture ........................................................................................................................123 Case Study #46--Removal of Painful Instrumentation and Placement of L5-S1 Rods ..................................................................125

Answers and Rationales ........................................................................................................................ 127

Case Study #1--Total Knee Arthroplasty ..................................................................................................................................................127 Case Study #2--Radial Shaft Fracture ........................................................................................................................................................129 Case Study #3--Total Hip Arthroplasty .....................................................................................................................................................131 Case Study #4--Periprosthetic Fracture of Femur ..................................................................................................................................133 Case Study #5--Trigger Finger Release .....................................................................................................................................................135 Case Study #6--Digital Neuroma ................................................................................................................................................................137 Case Study #7--Degenerative Joint Disease, Shoulder .........................................................................................................................138 Case Study #8--ACL Tear ..............................................................................................................................................................................140 Case Study #9--Radioulnar Synostosis ......................................................................................................................................................143 Case Study #10--Lunate Stress Fracture ...................................................................................................................................................145 Case Study #11--Fracture of Thumb ..........................................................................................................................................................147 Case Study #12--Gangrene of Foot ............................................................................................................................................................149 Case Study #13--Idiopathic Osteoporosis ................................................................................................................................................152 Case Study #14--Rupture of Quadriceps Tendon ...................................................................................................................................154 Case Study #15--Wrist Laceration with Tendon Injury .........................................................................................................................156 Case Study #16--Cervical Stenosis with Myelopathy ............................................................................................................................158 Case Study #17--Rotator Cuff and Labral Tear of Shoulder .................................................................................................................160 Case Study #18--ACL and Meniscus Injury, Knee ...................................................................................................................................162 Case Study #19--Meniscal Tear and Osteochondral Fracture, Knee ..................................................................................................164 Case Study #20--Degenerative Joint Disease, Shoulder ......................................................................................................................167 Case Study #21--Status Postlumbar Decompression with Osteoporosis .........................................................................................169 Case Study #22--Osteoarthritis and Myofascial Pain Syndrome ........................................................................................................172 Case Study #23--Left Foot Pain ..................................................................................................................................................................174 Case Study #24--Left Knee Pain ..................................................................................................................................................................176 Case Study #25--Humeral Fracture ............................................................................................................................................................178 Case Study #26--Distal Fibular Fracture ...................................................................................................................................................180 Case Study #27--Planovalgus Feet with Myotonic Muscular Dystrophy .........................................................................................182 Case Study #28--Chronic Plantar Fasciitis ................................................................................................................................................184 Case Study #29--Posterior Calf Pain ..........................................................................................................................................................186 Case Study #30--Bunion and Hammer Toe .............................................................................................................................................188 Case Study #31--Erythema of the Knee ....................................................................................................................................................190 Case Study #32--Chronic Pain .....................................................................................................................................................................192 Case Study #33--Back and Shoulder Pain ................................................................................................................................................194 Case Study #34--Carpal Tunnel Syndrome ..............................................................................................................................................197 Case Study #35--Lytic Lesion of Cervical Vertebrae ..............................................................................................................................199 Case Study #36--Patellar Tendon Rupture ...............................................................................................................................................201 Case Study #37--Above-the-Knee Amputation ......................................................................................................................................204 Case Study #38--Avascular Necrosis of Hip ............................................................................................................................................207

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ICD-10-CM Coding Workbook for Orthopaedics

Contents

Case Study #39--Neck Pain Following MVA ............................................................................................................................................ 209 Case Study #40--Shoulder Osteoarthritis ................................................................................................................................................ 211 Case Study #41--Trauma to Finger .......................................................................................................................................................... 214 Case Study #42--Open Tibia Fibula Fracture .......................................................................................................................................... 216 Case Study #43--Transmetatarsal Amputation ...................................................................................................................................... 219 Case Study #44--Displaced Fifth Metacarpal Fracture ......................................................................................................................... 221 Case Study #45--Follow-up for Tibial Plateau Fracture ....................................................................................................................... 223 Case Study #46--Removal of Painful Instrumentation and Placement of L5-S1 Rods ................................................................. 225

Appendix A. Quick Coding Reference ................................................................................................... 227

How to Use ........................................................................................................................................................................................................ 227 Spinal Conditions ............................................................................................................................................................................................ 229

ICD-10-CM Mapping ................................................................................................................................................................................ 231 Fractures ............................................................................................................................................................................................................ 235

ICD-10-CM Mapping ................................................................................................................................................................................ 237 Joint Conditions and Injuries ........................................................................................................................................................................ 265

ICD-10-CM Mapping ................................................................................................................................................................................ 268 Other Traumatic Injuries ................................................................................................................................................................................ 276

ICD-10-CM Mapping ................................................................................................................................................................................ 279 General Musculoskeletal ............................................................................................................................................................................... 290

ICD-10-CM Mapping ................................................................................................................................................................................ 292

Appendix B. ICD-10-CM Official Guidelines for Coding and Reporting 2016 ...................................... 295

Section I. Conventions, general coding guidelines and chapter specific guidelines .................................................................... 300 Section II. Selection of Principal Diagnosis .............................................................................................................................................. 351 Section III. Reporting Additional Diagnoses ............................................................................................................................................. 353 Section IV. Diagnostic Coding and Reporting Guidelines for Outpatient Services ........................................................................ 354

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Case Studies and Questions

Case Study #23--Left Foot Pain

ICD-10-CM Coding Workbook for Orthopaedics

Description

Consultation for left foot pain

Chief Complaint

Left foot pain

History

The patient is a basketball player for Optum University who was injured in a game one day prior. He jumped and came down twisting his foot and injuring it. He had an immediate onset of swelling and pain. The trainer taped up his foot and he was able to continue playing in the game. Following the game he was further examined by the trainer and had some tenderness around the navicular. The patient has been taped up firmly and in a walking boot since the game. He does have pain with any type of weightbearing activities and is limping a bit. He has not suffered any significant foot injuries in the past. The majority of the pain is located around the dorsal aspect of the hind and midfoot.

Physical Examination

Patient has swelling from the hindfoot out toward the midfoot. The arch is maintained however. Motion at the ankle and subtalar joints is preserved, and forefoot motion is intact. He complains of pain with adduction and abduction across the hindfoot, most of the discomfort presenting laterally. Motor strength is grossly intact, as is sensation. Pulses are strong and palpable. The ankle is not tender. There is no medial tenderness over the ATFL, along the deltoid, or the medial malleolus. His anterior drawer is solid. External rotation stress is not painful at the ankle. Tarsometatarsal joints 1, 2, and 3 are nontender. The majority of tenderness is found laterally along the calcaneocuboid joint and along the anterior process of the calcaneus. The patient notes some tenderness over the dorsolateral side of the talonavicular joint as well, although the medial talonavicular joint is nontender.

Radiology

Weightbearing radiographs of the foot show changes that appear chronic over the dorsal aspect of the navicular. There does not appear to be a definite fracture. Tarsometatarsal joints are anatomically aligned. Films of the ankle show no fractures but changes along the dorsal talonavicular joint. An MR scan was also reviewed, which shows some changes along the lateral side of the calcaneocuboid joint with disruption of the capsular area and lateral ligament. It also shows some changes to the dorsal talonavicular joint, but no significant marrow edema or definitive fracture line.

Impression

Left Chopart joint sprain

Plan

Continue with walking boot for weightbearing activities. Start a functional rehab program and progress back to activities as symptoms allow. Patient is aware that a prolonged duration of recovery is sometimes needed for this type of a hindfoot injury, and additional injury can occur if appropriate plan is not followed.

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