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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