Upper Extremity - PT Management
Upper Extremity
Shoulder
Medical Diagnosis
Left
Adhesive capsulitis Anterior dislocation of humerus
M75.02 S43.015 [7]
Anterior dislocation of SC joint Anterior subluxation of humerus
S43.215 [7] S43.012 [7]
Anterior subluxation of SC joint Bicipital tendinitis
S43.212 [7] M75.22
Bursitis Calcific Tendinitis
M75.52 M75.32
Contracture of muscle in shoulder Contracture of muscle in upper arm
M62.412 M62.422
Dislocation of AC joint (>200%)
S43.132 [7]
Right
M75.01 S43.014 [7] S43.214 [7] S43.011 [7] S43.211 [7]
M75.21 M75.51 M75.31 M62.411 M62.421
S43.131 [7]
Dislocation of AC joint (100%-200%)
S43.122 [7]
S43.121 [7]
Dislocation of scapula
S43.315 [7]
S43.314 [7]
Dislocation, recurrent
Encounter for other orthopaedic aftercare: USE for Labral Repair or SAD Joint replacement aftercare (use with a Z96.6- code below)
Presence of artificial shoulder joint Humeral Fracture Impingement Syndrome Inferior dislocation of AC joint Inferior dislocation of humerus Inferior subluxation of humerus Posterior dislocation of AC joint Posterior dislocation of humerus Posterior dislocation of SC joint Posterior subluxation of humerus Posterior subluxation of SC joint Rotator cuff tear or rupture, complete, not traumatic Rotator cuff tear or rupture, incomplete, not traumatic Shoulder (other) lesions
Sprain of AC joint
M24.412
M24.411
Z47.89
Z47.1
Z96.612 S42.202[7]
M75.42 S43.142 [7] S43.035 [7] S43.032 [7] S43.152 [7] S43.025 [7] S43.225 [7] S43.022 [7] S43.222 [7]
Z96.611 S42.201[7]
M75.41 S43.141 [7] S43.034 [7] S43.031 [7] S43.151 [7] S43.024 [7] S43.224 [7] S43.021 [7] S43.221 [7]
M75.122
M75.121
M75.112 M75.82 S43.52X [7]
M75.111 M75.81 S43.51X [7]
Sprain of rotator cuff capsule
Sprain of SC joint Subluxation of AC joint Subluxation of scapula Pain in upper arm Stiffness of shoulder
S43.422 [7]
S43.62X [7] S43.112 [7] S43.312 [7] M79.622 M25.612
S43.421 [7]
S43.61X [7] S43.111 [7] S43.311 [7] M79.621 M25.611
Elbow Medical Diagnosis
Anterior dislocation of radial head Anterior dislocation of ulnohumeral joint Anterior subluxation of radial head Anterior subluxation of ulnohumeral joint Contracture of muscle in forearm Contusion of elbow Elbow, (recurrent) dislocation Lateral epicondylitis Lesion of ulnar nerve, upper limb Long head of bicep tendon strain
Medial epicondylitis
Displaced simple supracondylar fracture without intercondylar fracture Non-displaced simple supracondylar fracture without intercondylar fracture Displaced comminuted supracondylar fracture without intercondylar fracture Non-displaced comminuted supracondylar fracture without intercondylar fracture
Olecranon bursitis
Posterior dislocation of radial head Posterior dislocation of ulnohumeral joint Posterior subluxation of radial head Posterior subluxation of ulnohumeral joint Radial collateral ligament sprain of elbow Radial nerve injury at forearm Radiohumeral (joint) sprain of elbow Sprain (other) of elbow Ulnar collateral ligament sprain of elbow Ulnohumeral sprain of elbow
Treatment Diagnosis
Effusion of elbow
Pain in arm
Pain in elbow
Pain in forearm
Stiffness of elbow, not elsewhere classified
Left
S53.015 [7] S53.115 [7] S53.012 [7] S53.112 [7] M62.432 S50.02X [7] M24.422
M77.12 G56.22 S46.112 [7]
M77.02
S42.412[7]
S42.415[7]
S42.422[7]
S42.45[7]
M70.22
S53.025 [7] S53.125 [7] S53.022 [7] S53.122 [7] S53.432 [7] S54.22X [7] S53.412 [7] S53.492 [7] S53.442 [7] S53.422 [7]
Left
M25.422
M79.602
M25.522
M79.632
M25.622
Right
S53.014 [7] S53.114 [7] S53.011 [7] S53.111 [7] M62.431 S50.01X [7] M24.421
M77.11 G56.21 S46.111 [7]
M77.01
S42.411[7]
S42.414[7]
S42.421[7]
S42.424[7]
M70.21
S53.024 [7] S53.124 [7] S53.021 [7] S53.121 [7] S53.431 [7] S54.21X [7] S53.411 [7] S53.491 [7] S53.441 [7] S53.421 [7]
Right
M25.421
M79.601
M25.521
M79.631
M25.621
Wrist/Hand
Medical Diagnosis
Left
Boutonniere deformity of fingers Carpal Tunnel Syndrome, upper limb
M20.022 G56.02
DeQuervain tenosynovitis Dislocation of MCP joint IF
M65.4 S63.261 [7]
Dislocation of MCP joint of LF Dislocation of MCP joint of MF
S63.267 [7] S63.263 [7]
Dislocation of MCP joint of RF Dupuytrens
S63.265 [7] M72.0
Mallet finger Osteochondritis dissecans of wrist Primary, unilateral OA of first carpometacarpal joint (OA of thumb)
M20.012 M93.232
M18.12
Sprain of carpal joint
S63.512 [7]
Sprain of radiocarpal joint Swan neck deformity of fingers
S63.522 [7] M20.032
Transient synovitis of wrist
M67.332
Trigger finger index finger
Trigger finger little finger Trigger finger middle finger Trigger finger ring finger Trigger thumb Ulnar entrapment at wrist/hand Wrist contusion Wrist ganglion Wrist sprain other specified
Treatment Diagnosis
Effusion of hand Effusion of wrist
Pain in fingers
M65.322
M65.352 M65.332 M65.342 M65.312 S64.02X [7] S60.212 [7] M67.432 S63.592 [7]
Left
M25.442 M25.432
M79.645
Pain in hand Pain in wrist Stiffness of hand, not elsewhere classified
M79.642 M25.532 M25.642
Stiffness of wrist, not elsewhere classified
M25.632
Right
M20.021 G56.01
S63.260 [7] S63.266 [7] S63.262 [7] S63.264 [7]
M20.011 M93.231 M18.11
S63.511 [7]
S63.521 [7] M20.031
M67.331
M65.321 M65.351 M65.331 M65.341 M65.311 S64.01X [7] S60.211 [7] M67.431 S63.591 [7]
Right
M25.441 M25.431
M79.644
M79.641 M25.531
M25.641
M25.631
If [7] noted above for code, add one of the following letters as the 7th character: A=initial encounter-which is generally not used in therapy unless the injury is first treated by the therapist; D=subsequent encounter-for healing/recovery phase which will typically be used by the therapist; S=sequela-for complications or conditions that arise as a direct result of a condition.
Lower Extremity and Spine
Hip Medical Diagnosis
Adductor muscle strain, fascia and tendon of thigh Bursitis Encounter for other orthopaedic aftercare: USE for Labral Repair Gluteal Tendinitis Hip contusion Injury of femoral nerve at hip and thigh
Injury of sciatic nerve at hip and thigh
Joint replacement aftercare (use with a Z96.6- code below) Presence of artificial hip joints, right or left Presence of artificial hip joint, bilateral
Other Bursitis Other specific joint derangements of hip, not elsewhere classified Other sprain hip
Psoas tendinitis
Recurrent dislocation Snapping hip Transient synovitis Trochanteric bursitis Unilateral primary OA of hip
Treatment Diagnosis
Pain in hip Pain in thigh Stiffness in hip Abnormal posture Difficulty walking General edema History of falling Localized edema Other abnormal gait and mobility Other Lack of Coordination Repeated falls
Unsteadiness on feet
Cervical & Headache
Medical Diagnosis
Cervical radiculopathy Cervical spinal stenosis Cervical spondylolisthesis Cervical spondylolysis Cervicalgia/Neck Pain Chronic post-traumatic headache, not intractable "HNP" use: Other cervical disc displacement, C2-2, C2-4 "HNP": Other cervical disc displacement, C4-5 "HNP":Other cervical disc displacement, C5-6 "HNP": Other cervical disc displacement, C6-7 "HNP": Other cervical disc displacement, C7-T1
"DDD": Other cervical disc degeneration, C2-3, C3-4
"DDD": Other cervical disc degeneration, C4-5 "DDD": Other cervical disc degeneration, C5-6 "DDD": Other cervical disc degeneration, C6-7
"DDD": Other cervical disc degeneration, C7-T1
Encounter for other orthopaedic aftercare: USE for s/p Fusion
Episodic tension type headache, not intractable Other spondylosis with myelopathy Post-traumatic headache, not intractable Spinal stenosis cervicothoracic Sprain of ligament of cervical spine Strain of muscle, fascia and tendon at neck level Torticollis
Treatment Diagnosis
Cervical pain
Left
Right
S76.212[7]
S76.211[7]
M70.72
M70.71
Z47.89
M76.02 S70.02X [7] S74.12X [7]
M76.01 S70.01X [7] S74.11X [7]
S74.02X [7]
S74.01X [7]
Z47.1 Z96.642 Z96.643 M70.72 M24.852 S73.192[7]
Z47.1 Z96.641
M70.71 M24.851 S73.191[7]
M76.12
M76.11
M24.452 R29.4
M67.352 M70.62 M16.12
Left
M24.451
M67.351 M70.61 M16.11
Right
M25.552
M25.551
M79.652
M79.652
M25.652
M25.651
R29.3
R26.2
R60.1
Z91.81
R60.0
R26.89
R27.8 R29.6
R26.81
M54.12 M48.02 M43.12 M43.02 M54.2 G44.329 M50.21 M50.221 M50.222 M50.223 M50.23 M50.31
M50.321 M50.322 M50.323
M50.33
Z47.89
G44.219 M47.12 G44.309 M48.03 S13.4 [7] S16.1 [7] M43.6
M54.2
Knee Medical Diagnosis
Bucket-handle tear of lateral meniscus, current injury Bucket-handle tear of medial meniscus, current injury Bursitis Chondromalacia of patella Complex tear of lateral meniscus current injury Complex tear of medial meniscus, current injury Encounter for other orthopaedic aftercare: USE for ACL repair or other surgery to knee Joint replacement aftercare (use with a Z96.6- code below) Presence of artificial knee joints, bilateral Presence of artificial knee joint, right or left Patellar tendonitis Patellofemoral disorders Peripheral tear of lateral meniscus, current injury
Peripheral tear of medial meniscus, current injury
Plica Sprain of ACL Sprain of LCL Sprain of MCL Sprain of PCL Strain of Achilles tendon
Transient synovitis Unilateral primary OA of knee
Treatment Diagnosis
Effusion in knee Pain in knee Phantom Limb Syndrome Stiffness in knee, not elsewhere classified
Left
S83.252 [7] S83.212 [7]
M70.52 M22.42 S83.272 [7] S83.232 [7]
Right
S83.251 [7] S83.211 [7]
M70.51 M22.41 S83.271 [7] S83.231 [7]
Z47.89
Z47.1
Z96.653
Z96.652
Z96.651
M76.52
M76.51
M22.2X2[7]
M22.2X1[7]
S83.262 [7]
S83.261 [7]
S83.222 [7]
S83.221 [7]
M67.52 S83.512 [7] S83.422 [7] S83.412 [7]
M67.51 S83.511 [7] S83.421 [7] S83.411 [7]
S83.522 [7]
S83.521 [7]
S86.012 [7]
S86.011 [7]
M67.362
M67.361
M17.12
M17.11
Left
Right
M25.462
M25.461
M25.562
M25.561
G54.6
M25.662
M25.661
Lumbosacral Medical Diagnosis
Encounter for other orthopaedic aftercare: USE for s/p lumbar fusion, discectomy or laminectomy Lumbago with sciatica Lumbar, other, disc intervertebral degeneration Lumbar nerve root injury Lumbar radiculopathy Lumbar spinal stenosis Lumbar spondylolisthesis Lumbar spondylolysis "DDD" use: Lumbosacral, other, disc intervertebral degeneration Lumbosacral radiculopathy Lumbosacral spinal stenosis Lumbosacral spondylosis w/o myelopathy
"HNP" use: Other lumbar disc displacement
"HNP" use: Other lumbosacral disc displacement Sciatica Spondylolysis, other, with myelopathy
Sprain of sacroiliac joint
Treatment Diagnosis
Chronic pain syndrome Chronic pain, not elsewhere classified Low back pain
Left
Right
Z47.89
M54.42
M54.41
M51.36
S34.21X [7]
M54.16
M48.06
M43.16
M43.06
M51.37
M54.17
M48.07
M47.817
M51.26
M51.27
M54.32
M54.31
M47.16
S33.6XX [7]
G89.4 G89.2 M54.5
Foot/Ankle Medical Diagnosis
Achilles bursitis or tendinitis Calcaneal spur in foot Contusion of ankle Contusion of foot Encounter for other orthopaedic aftercare: USE for Bi-malleolar FX s/p ORIF Flat foot pes planus acquired
Hallus valgus
Lesion of plantar nerve Mallet finger Other hammer toe Plantar fasciitis (same for L or R) Recurrent dislocation of ankle Sprain of calcaneofibular ligament
Sprain of deltoid ligament
Sprain of foot, other specified Sprain of internal collateral or talofibular ligament Sprain of tibiofibular ligament Sprain of other specified ligament of ankle Tarsal tunnel syndrome Transient synovitis of ankle
Treatment Diagnosis
Effusion in ankle/foot Pain in ankle Pain in foot Stiffness in foot, not elsewhere classified
Left
Right
M76.62
M76.61
M77.32
M77.31
S90.02X [7]
S90.01X [7]
S90.32X [7]
S90.31X [7]
Z47.89
M21.4
M20.12
M20.11
G57.62 M20.12 M20.42 M72.2 M24.472 S93.412[7]
G57.61 M20.11 M20.41 M72.2 M24.471 S93.411[7]
S93.422[7]
S93.421[7]
S93.692 [7] S93.492[7] S93.432[7] S93.492 [7]
G57.52 M67.372
Left
M25.472 M25.572 M79.672 M25.675
S93.691 [7] S93.491[7] S93.431[7] S93.491 [7]
G57.51 M67.371
Right
M25.471 M25.571 M79.671 M25.674
Medical Diagnosis
Thoracic
Adolescent Idiopathic scoliosis
Encounter for other orthopaedic aftercare Fibromyalgia Postural kyphosis Thoracic disc intervertebral stenosis of neural canal Thoracic radiculopathy Thoracic spine ligaments sprain Thoracogenic scoliosis
Treatment Diagnosis
Thoracic pain in spine
M41.124
Z47.89 M79.7 M40.00 M99.52 M54.14 S23.3XX [7] M41.34
M54.6
If [7] noted above for a code, add one of the following letters as the 7th character: A=initial encounter-which is generally not used in therapy unless the injury is first treated by the therapist; D=subsequent encounter-for healing/recovery phase which will typically be used by the therapist; S=sequela-for complications or conditions that arise as a direct result of a condition.
Type of Fracture Traumatic (caused by some type of accident, fall or other kind of force
Pathological (caused by disease); if the force from a trauma is insufficient to break a healthy bone, the fracture is pathologic. Not all pathologic fractures are due to cancer. Insufficient documentation of pathologic fractures is problematic; the physician must document whether a fracture is pathologic.
Osteoporosis and fracture coding:
Fracture Coding General Rules with Some Common Fractures
Site of Fracture Include specific location of fracture on fractured bone Include multiple sites and/or right and left side (if no multiple site code is available, use separate codes for each fracture) Documentation regarding specifics of the fracture: displaced, comminuted, open, closed
Tibial Plateau
Category M80- denotes fractures caused by osteoporosis. Select the code based on the site of the fracture, not the location of the osteoporosis.
Medical Diagnosis
Note that codes for pathologic fractures with osteoporosis also require a seventh character to indicate episode of care.
Proximal Humeral Fracture
Medical Diagnosis
Left
Right
Fracture, humerus, upper end unspecified
S42.202 [7]
S42.201 [7]
Anatomical neck (displaced) Anatomical neck (nondisplaced)
S42.292 [7] S42.295 [7]
S42.291 [7] S42.294 [7]
Articular Head (displaced)
S42.292 [7]
S42.291 [7]
Articular Head (nondisplaced) Epiphysis (see Physeal) Greater tuberosity (displaced) Greater tuberosity (nondisplaced) Lesser Tuberosity (displaced)
Lesser Tuberosity (nondisplaced)
S42.295 [7] S49.00_ [7] S42.252 [7] S42.255 [7] S42.262 [7]
S42.265 [7]
S42.294 [7] S49.00_ [7] S42.251 [7] S42.254 [7] S42.261 [7]
S42.264 [7]
Physeal
S49.002 [7]
S49.001 [7]
Salter-Harris Type I
S49.012 [7]
S49.011 [7]
Salter-Harris Type II
Salter Harris Type III Salter Harris Type IV Physeal Specified *NEC Specified *NEC (displaced) Specified *NEC (nondisplaced) Surgical neck, unspecified (displaced) Surgical neck, unspecified (nondisplaced) Surgical neck four-part Surgical neck three-part Surgical neck two-part (displaced) Surgical neck two-part (nondisplaced) Torus Transperiphyseal (see physeal)
Medical Diagnosis
Unspecified part of clavicle Acromial end (displaced ) Acromial end (nondisplaced ) Lateral end (see acromial end) Shaft (displaced) Shaft (nondisplaced) Sternal end (anterior) (displaced) Sternal end (anterior) (nondisplaced) Sternal end (posterior)
S49.022 [7]
S49.032 [7] S49.042 [7] S49.092 [7]
S42.292 [7]
S42.295 [7] S42.212 [7] S42.215 [7] S42.242 [7] S42.232 [7] S42.222 [7] S42.225 [7] S42.272 [7] S49.00_ [7] Clavicle
Left
S42.002 [7] S42.032 [7] S42.035 [7] S42.032 [7] S42.022 [7] S42.025 [7] S42.012 [7] S42.018 [7] S42.015 [7]
S49.021 [7]
S49.031 [7]
S49.041 [7] S49.091 [7] S42.291 [7] S42.294 [7] S42.211 [7] S42.214 [7] S42.241 [7] S42.231 [7] S42.221 [7] S42.224 [7] S42.271 [7] S49.00_ [7]
Right
S42.001 [7] S42.031 [7] S42.034 [7] S42.031 [7] S42.021 [7] S42.024 [7] S42.011 [7] S42.017 [7] S42.014 [7]
Fracture, tibia, upper end
Bicondylar (displaced) Bicondylar (nondisplaced) Lateral condyle (displaced) Lateral condyle (nondisplaced) Medial condyle (displaced) Medial condyle (nondisplaced) Physeal Salter-Harris Type I Physeal Salter-Harris Type II Physeal Salter-Harris Type III Physeal Salter-Harris Type IV Physeal Physeal Specified NEC*
Tibial spine (displaced)
Tibial spine (nondisplaced)
Tours
Tuberosity (displaced)
Tuberosity (nondisplaced)
Medical Diagnosis Other fracture of lower let Bimalleolar (displaced) Bimalleolar (nondisplaced) Lateral malleolus only (displaced) Lateral malleolus only (nondisplaced) Medial malleolus (displaced) Medial malleolus (nondisplaced) Talus unspecified Talus avulsion (displaced) Talus avulstion (nondisplaced) Talus body (displaced) Talus body (nondisplaced) Talus dome (displaced) Talus dome (nondisplaced) Talus head (displaced) Talus head (nondisplaced) Talus lateral process (displaced) Talus latearal process (nondisplaced) Talus neck (displaced) Talus posterior process (displaced) Talus posterior process (non displaced) Talus specified NEC
* If [7] noted above for a code, add the appropriate seventh character from the choices in the third column, upper right of this sheet.
Left
S82.102 [7]
S82.142 [7] S82.145 [7] S82.122 [7] S82.125 [7] S82.132 [7] S82.135 [7] S89.002 [7] S89.012 [7] S89.022 [7] S89.032 [7] S89.042 [7] S89.092 [7]
S82.112 [7]
S82.115 [7]
S82.162 [7]
S82.152 [7]
S82.155 [7] Ankle
Left S82.892 [7] S82.842 [7] S82.845 [7] S82.62X [7] S82.65X [7] S82.52X [7] S82.55x [7] S92.102 [7] S92.152 [7] S92.155[7] S92.122 [7] S92.125 [7] S92.142 [7] S92.145 [7] S92.122 [7] S92.125 [7] S92.142 [7] S92.145 [7] S92.112 [7] S92.132 [7] S92.135 [7] S92.192 [7]
Right
S82.101 [7]
S82.141 [7] S82.144 [7] S82.121 [7] S82.124 [7] S82.131 [7] S82.134 [7] S89.001 [7] S89.011 [7] S89.021 [7] S89.031 [7] S89.041 [7] S89.091 [7]
S82.111 [7]
S82.114 [7]
S82.161 [7]
S82.151 [7]
S82.154 [7]
Right S82.891 [7] S82.841 [7] S82.844 [7] S82.61X [7] S82.64x [7] S82.51x [7] S82.54X [7] S92.101 [7] S92.151 [7] S92.154 [7] S92.121 [7] S92.124 [7] S92.141 [7] S92.144 [7] S92.121 [7] S92.124 [7] S92.141 [7] S92.144 [7] S92.111 [7] S92.131 [7] S92.134 [7] S92.191[7]
Therapy will almost always use "D" as the 7th character * [7] Seventh Character Relates to Initial or Subsequent Visit
The meaning of the seventh character for ICD-10-CM codes varies according to chapter and category
Fracture codes are an example of codes for which the seventh character includes additional information about the type of encounter
When coding a closed fracture, add one fo the following seventh characters to each code:
A: Initial encounter for fracture (report while the patient is receiving active treatment for the injury including surgical treatment, ED encounter, or evaluation and treatment by a new physician).
D: Subsequent encounter for fracture with routine healing. (Extensions for D, G, K and P denote encounters after the patient has received active treatment of the injury and receives routine care for the injury during the healing or recovery phase. These type of encounters include: cast change or removal, removal of external or internal fixation device, medication adjustment or other aftercare and follow-up visits.)
G: Subsequent encounter for fracture with delayed healing
K: Subsequent encounter for fracture with nonunion
P: Subsequent encounter for fracture with manunion
S: Sequela
Disorder of Continuity of Bone - Stress Fracture
Medical Diagnosis
Left
Stress fracture, ankle
M84.372 [7]
Stress fracture, foot
M84.375 [7]
Stress fracture, toes
M84.378 [7]
Contusion of the Bone
Other injury of unspecified body region
T14.8
Wrist and Hand
Medical Diagnosis
Left
Displaced fracture of proximal phalanx of index finger
S62.611[7]
Right M84.371 [7] M84.374 [7] M84.377 [7]
T14.8
Right
S62.610[7]
Displaced fracture of proximal phalanx of little finger
Displaced fracture of proximal phalanx of middle finger
Displaced fracture of proximal phalanx of ring finger
Displaced fracture of proximal phalanx of thumb Other extraarticular fracture of lower end of radius Other fractures of the lower end of the radius Other intraarticular fracture of lower end of radius Torus fracture of lower end of radius
S62.617[7]
S62.613[7]
S62.615[7] S62.512[7] S52.552[7] S52.592[7] S52.572[7] S52.522[7]
S62.618[7]
S62.612[7]
S62.614[7] S62.511[7] S52.551[7] S52.591[7] S52.571[7] S52.521[7]
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