Today we're going to talk about Chapter
13 in our ICD-10-CM codebook- the
2017 guidelines . Chapter 13 is the
Diseases of the Musculoskeletal System
and Connective Tissue. Most of the codes
within Chapter 13 have site and
laterality. In other words, right, left or
bilateral designations. The site itself
represents the bone, the joint or the
muscle involved and for some conditions,
when there's more than one bone, joint or
muscle involved, such as osteoarthritis,
there is a "multiple sites" code available
for the coder to select. For those
categories where no multiple site code is
provided and more than one bone, joint or
muscle is involved, the coder can use
multiple codes to indicate the different
sites involved. So we're going to go
through several examples here that talk
about this guideline that has to do with
site and laterality. The first one is a
right elbow infected bursitis MRSA positive.
So i have here on the right the
index pathway you would use. You notice
that there is an instructional note
under the M71.12- code that says "use
additional code to identify the
causative organism". We know from our
examples from Chapter 1 that we would
start with a main term "infection"
staphylococcal, to follow the pathway
there until you get to B95.62.
This is just using this guideline that
tells us that most of the codes within
the Chapter 13 have site and laterality
designation and the site represents
whatever bone or joint or muscle is
involved. The next example is rheumatoid
arthritis of multiple sites without
rheumatoid factor. I have here a note
for you that you need to remember that
the coder is going to use the term "seronegative"
or negative serum. Seronegative
to indicate the rheumatoid factor is not
present in the serum so our index pathway is
shown here and you notice that seronegative
is one of our subterms.
We choose a multiple site designation
and that gives us M06.09 and the
rationale is just pointing back to that
part of the guideline that says there's a
"multiple sites" code available but here's
an example when there is no multiple
cite code available. We would use as
many codes as needed to indicate the
different sites involved and it is for
osteomyelitis of the fourth thoracic and
the second lumbar vertebrae. You see
when we go to the index pathway, it is
just by region, not the specific
vertebrae involved. The first was the
thoracic and the second is the lumbar. The next guideline has to do with the
bone versus the joint. Now, what are we
talking about when we're looking at
different descriptions. I'm using
this one as an example for you to not
only learn some new terms but to also
know that you are, many times, going to be
looking at more than one guideline when
you're making decisions about the
sequencing of your codes. In this
particular example, the patient's
diagnosed with idiopathic avascular
necrosis which is abbreviated as an AVN. It
is of the femoral head of the left hip
joint. The patient is HIV infected and
the AVN is due to the HIV. So your doctor's
telling you that the patient's condition
is due to AIDS. That should immediately
bring to your attention a guideline
found in Chapter 1that has to do with
HIV positive patients. There are also
notes here to help you know that you're
going to use the term "aseptic" instead of
the term "avascular" in the index and that
would just be to make yourself a note. I
would say (to write it) by the necrosis main term, just
put a little note or something that says
"aseptic" instead of "avascular" or
something like that. just to help you
remember that. Then I have the second
note there just to teach you about AVN.
That is just a condition that
occurs as a result of the interruption
of blood to the bone. It causes the bone to
die.
The most common site is the hip but it's
not the only site that can be affected.
AVN is most typically associated
with either trauma where the bone,
the blood supply of the bone is
cut off because of some interruption in
the bone, like us cutting through a
vessel or non-trauma like diseases, such
as HIV, sickle-cell, pancreatitis or
radiation therapy or chemotherapy where
the flow of blood is being affected by
those agents. Then I have, on the right,
the path that you would use to find
those codes. The osteonecrosis code
you would find the M87.05-. There's
a 6th character added to indicate it is the
"left" femur and the guidelines that we're
talking about here is the one that says
the site designation will be the bone,
not the joint so even though the femoral
head is where the necrosis is taking
place, the femoral head of the left hip
joint would be where the femur goes
into the left hip joint, you're going to
base your site designation on what the bone
is there and the bone is the femur so
the site designation is the femur. Then I
have the guideline that reminds us from
Chapter 1 where a patient admitted for
HIV-related condition, the principal
should B20 followed by
additional diagnosis codes for all
reported HIV-related conditions. So it would be
B20, which would be your principal
diagnosis according to your guideline
and M87.052 would be
your secondary diagnosis.
The next guideline has to do with the
coding of acute traumatic injuries
versus chronic or recurrent
musculoskeletal conditions. The example
that's given is acute traumatic buckle
handle tear of the right medial meniscus.
The medial meniscus is a cartilage in
the right knee> "Acute traumatic"- those
words are telling us it's acute, this is
not an old injury. This is not a
recurrent injury or a chronic injury.
This is an acute traumatic injury and
our guidelines tell us that when that's
the case, acute (current) injuries are
coded to the appropriate injury code
from Chapter 19. So following the coding,
the index pathway there, you see S83
category code and that is in Chapter 19.
Your documentation is what
helps you know what chapter you're even
going to be looking in. Here's an
example of an old bucket handle tear of
the right medial meniscus. It's the very
same tear, but the word "old" instead of
"acute traumatic" is being used to
describe the tear and that takes us to a
completely different index pathway where
Tear, meniscus, old says "see derangement," (and when we go there)
"derangement, knee, meniscus, due to old tear or injury,
further specified as "medial". The 6th
character "3" is added to this code to
indicate it is the "right" knee and it is
the medial meniscus. The part of the
guideline that I'm following is in
purple (font color). The chronic or recurrent
conditions should be coded with a code
from Chapter 13. This is a chronic or
old injury of the right medial meniscus.
This guideline has to do with the coding
of pathologic fractures These are
fractures that are associated with some
disease process or osteoporosis.
This particular guideline has to do with
the 7th character (the use of the 7th character).
You see that our scenario says
pathologic fracture of the left foot.
That's an unknown cause and it's
currently under active treatment by a
follow-up provider. The phrase "under
active treatment" tells a coder that
you're going to be coding the 7th
character "A" for initial encounter.
The guideline tells us while the patient
can be seen by a new or a different
provider over the course of treatment,
assignment of the 7th character is based
on whether the patient is undergoing
"active treatment", not whether they're
seeing the same patient or the same
provider but whether they are receiving
active treatment. You also find when you
look up this code, there is no fracture
code with a subterm for "foot", so you would
use "ankle". You could use a tarsus
bone.,whichever one you use. it takes you
to the same M84.47 code.When you look
at this M84.47 code, you see that it's
a fracture of the ankle and foot and
what you may remember from way back in
our earlier guidelines, when "and" is used
in this respect in a description, it
really means "or" so this code is for a
fracture of the foot "or" a fracture of
the ankle. You do not have to have a
fracture of the foot and the ankle to
have this code.
The next guideline has to do with
osteoporosis. This is a systemic
condition meaning that all bones and the
musculoskeletal system are affected so
when you are talking about a patient
with osteoporosis, the "site" is not a
component of the codes. Under category
M81, which is osteoporosis without
current pathological fracture, those
codes under category M80 which is
osteoporosis with a current pathological
fracture do identify the site of the
fracture but they do not identify the
osteoporosis. So let's look at an example.
Osteoporosis without pathological
fracture is an M81 code and our
scenario is age-related osteoporosis
with a healed osteoporotic fracture of
the lumbar vertebrae. When we see that
"healed osteoporotic fracture" that should
remind us of a Z code which is a "history"
"personal history" code and there is a
guideline (this one) that tells us
category M81 is for use with patients
with osteoporosis who do not currently
have a pathological fracture. So the
fracture he had is healed. It's not
current. If he had a fracture in the past
that's healed, you're going to use code Z 87.310
which is a personal history of a
healed osteoporotic fracture. Our
guidelines for sequencing tell us that
that healed fracture code Z87 should
follow the code from M81. As I've said in
prior lectures, often the guidelines tell
us how to sequence these codes. We just
have to remember to read them. Here's
an example of osteoporosis with a
current pathological fracture- disuse
osteoporosis with current fracture of
the right shoulder sustained lifting a
grocery bag. The definition of "disuse
osteoporosis" would be your bones are
just so osteoporotic and you break
doing things that normally would not
cause a break. So when you choose a
category code from M80, this would tell a
reader or the doctor this is a
pathologic fracture but it's due to
someone having osteoporosis and not
using those bones in any way. The
shoulder is coded to the scapula which
is the winged bone there in your upper
back. The important thing about this code
is remembering that normally someone
lifting a grocery bag would not break
their shoulder but because someone has
osteoporosis, it should just remind us
that this is more than likely a
pathologic fracture and it's due to this
osteoporosis which is your M80 code
M80 category code. Please post any
questions about Chapter 13 coding
guidelines in the discussion board and I
will attempt to answer them. I hope
that you watch this podcast more than
once, especially about those osteoporosis
codes. I think it's easy to just code an
acute injury with a "S" code (Chapter 19) instead of
remembering these M codes that identify
osteoporosis as the underlying condition.
Thank you so much and have a good day.