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The clinical concepts for orthopedics guide includes common ICD-10 codes, clinical documentation tips and clinical scenarios.

ICD-10 Clinical Scenarios for Orthopedics

  • Scenario 1: Fracture Follow-Up Visit
  • Scenario 2: Shoulder ROM Office Visit
  • Scenario 3: Tear of Medial Meniscus With Anterior Cruciate Ligament Injury
  • Scenario 4: Right Shoulder Pain & Possible Rotator Cuff Tear
  • Scenario: Cervical Disc Disease
  • Scenario: Struck by Car
  • Scenario: Fracture

Quality clinical documentation is essential for communicating the intent of an encounter, confirming medical necessity, and providing detail to support ICD-10 code selection. In support of this objective, we have provided outpatient focused scenarios to illustrate specific ICD-10 documentation and coding nuances related to your specialty.The following scenarios were natively coded in ICD-10-CM and ICD-9-CM. As patient history and circumstances will vary, these brief scenarios are illustrative in nature and should not be strictly interpreted or used as documentation and coding guidelines. Each scenario is selectively coded to highlight specific topics; therefore, only a subset of the relevant codes are presented.

Scenario 1: Fracture Follow-Up Visit

Assessment and Plan

  • Left femur fracture is healing appropriately.
  • Discontinue home PT. Patient to begin daily rehab at PT Center tomorrow. Continue to increase PT exercises. Updated orders sent to PT office and discussed with patient.
  • See patient in office in 4 weeks for repeat films, evaluation of surgical site and PT progression.

Summary of ICD-10-CM Impacts

Clinical Documentation
1. Describes circumstances of injury. With ICD-10-CM, you must re-document or reference extensive details surrounding the circumstances of injury to ensure correct coding and proper claims processing. This includes timeframe, etiology, episode of care, injury site, cause, and place of occurrence. According to the ICD-10-CM guidelines, place of occurrence, activity and work status codes are only coded on the first visit. Assign the external cause code, with the appropriate 7th character (initial encounter, subsequent encounter or sequelae) for each encounter for which the injury or condition is being treated. As this is a subsequent encounter, this information is reflected in the 7th character of the ICD-10-CM code (e.g., V83.7xxD for V83.7xxD, Person on outside of special industrial vehicle injured in nontraffic accident).
Note that per the guidelines there is no national requirement for mandatory ICD-10-CM external cause code reporting. You may be required to report them based on a state based external cause code mandate (for example, for a trauma registry) or as required by a particular payor. Providers are encouraged to voluntarily report external cause codes, as they provide valuable data for injury research and may assist in claims processing/insurance coordination of benefits.
2. Describes the fracture/injury – With ICD-10-CM, you need to document specifics about the type of fracture injury to ensure correct coding. Include information on the side, location (make reference to the appropriate anatomical landmarks) and classification. The fracture description above is well defined and includes description that supports the necessary items such as traumatic, open, displaced, middle of femur shaft, subsequent encounter, routine healing, and fracture classification Gustilo class II. This information is reflected in the 7th character of the ICD-10-CM code (e.g., S72.322E)
3. Note the presence of infection (if any). Documenting whether there are signs of infection will support if additional surgical intervention is necessary and if additional adverse sequelae develop.

Other Impacts

  • Correctly coding the fracture ensures the provider will be reimbursed for appropriate follow-up visits and that the patient can receive appropriate outpatient (i.e. PT, imaging, etc.) services. Uncomplicated follow-up visits may be bundled by a payor.
  • The circumstances of injury such as where and how it occurred are important for claims processing and coordination of benefits.

Coding

ICD-9-CM Diagnosis Codes
821.11 Open fracture of shaft of femur
E919.2 Accidents caused by lifting machines and appliances
ICD-10-CM Diagnosis Codes
S72.322E Displaced transverse fracture of shaft of left femur, subsequent encounter for open fracture type I or II with routine healing
W23.0xxD Caught, crushed, jammed, or pinched between moving objects subsequent encounter
V83.7xxD Person on outside of special industrial vehicle injured in nontraffic accident

Scenario 2: Shoulder ROM Office Visit

Scenario Details

Chief Complaint

  • “Frozen” right shoulder1

History

  • 52 year old female with right shoulder pain; “6” on 1-10 scale. Seen in my office two weeks ago for same c/o; prolonged symptoms after oral non-steroidal challenge. Decreased ROM noted. Difficulty with daily activities including carrying briefcase, driving, dressing and cooking noted. Patient states sleep is also being affected.
  • Takes NSAID twice daily for pain. Patient reports the medication “helps some.”

Exam

  • Right shoulder film negative. Tenderness noted.
  • Active and passive range of motion remain to right shoulder is significantly decreased.
  • Neurological exam normal.

Assessment and Plan

  • Adhesive capsulitis of right shoulder.
  • Administered subacromial corticosteroid injection, right shoulder.
  • Pain control discussed. Patient declines Rx oral corticosteroid medications. Recommended to continue with NSAID, discussed side effects.
  • PT therapy for ROM of shoulder
  • Scheduled a follow-up visit in 2 weeks.

Summary of ICD-10-CM Impacts

Clinical Documentation
1. ICD-10-CM can now capture the side and specific bone or joint. Including the specific information ensures the correct “side” code is assigned.
2. Be as specific as possible when describing the effects of the condition.

Coding

ICD-9-CM Diagnosis Codes
726.0 Adhesive capsulitis of shoulder

ICD-10-CM Diagnosis Codes
M75.01 Adhesive capsulitis of right shoulder

Other Impacts

Identifying the affected side is important, as some payers will not reimburse claims with “unspecified” codes.

Scenario 3: Tear of Medial Meniscus With Anterior Cruciate Ligament Injury

Scenario Details

Chief Complaint

  • Instability of right knee.

History

  • This 29 year old single male, new patient, presents today for evaluation of an injury to his right knee. Patient states he initially injured his right knee one year ago playing hockey and then reinjured the same knee three weeks ago playing softball.
  • He describes the pain as 6/10, with throbbing intermittently; pain does not interfere with sleep. He states the symptoms are made worse with exercise, squatting, kneeling, and certain twisting motions. Locking and clicking present. Symptoms seem to improve with rest and no physical activity.
  • MRI from one year ago shows partial right anterior cruciate ligament tear.
  • MRI films following an ER visit three weeks ago show a tear of the right medial meniscus.
  • Treatment has consisted of bracing and exercise. He has had no physical therapy, no injections, and has never used a cane or a crutch.
  • He complains of instability of his right knee, especially with directional change and specifically with pivoting.
  • No history of rheumatoid arthritis or osteoarthritis.
  • 13 point review of systems negative; past medical history noncontributory.

Exam

  • Vital signs: BP: 110/65 HR: 61 R: 20 T: 98.6 Ht: 6.0 Wt: 201 lbs.
  • Slight antalgic gait observed.
  • No gross deformities of the lower extremities, range of motion of the both knees is within normal limits. Palpable patellofemoral crepitation with moderate positive patellar squeeze test.
  • Obvious grade 2 to 3+ Lachman exam with poor endpoint and grossly positive shift.
  • Pain present with palpation to the mid portion of the medial joint line; aggravated by Apley compression test and McMurray maneuver.
  • Effusion palpable.
  • Posterior cruciate ligament and collateral ligaments appear intact.
  • Neurovascular exam intact bilaterally.
  • Remainder of physical examination within normal limits.

Assessment and Plan

  • Medial meniscus tear of right knee; symptomatic with pain and instability.
  • Functional instability due to anterior cruciate ligament insufficiency.
  • Will treat conservatively for now.

Summary of ICD-10-CM Impacts

Clinical Documentation
1. In ICD-10-CM, old disruptions of any of the four knee ligaments map to chronic instability of the knee. Following coding guidelines in both ICD-9 and ICD-10, the old disruption and chronic instability are not reported in addition to the current injury.
2. Pain may be considered integral to the underlying medical condition of the medial meniscus tear, and thus is not coded separately as a symptom.
3. In this example, the medial meniscus tear is coded with unspecified as the information in the medical record is insufficient to assign a more specific code (e.g., bucket handle, peripheral). “Other” [forms] would be used when the information in the medical record provides detail for which a specific code does not exist.

Other Impacts

S83.2Ø6 has a 7th character based on initial encounter, subsequent encounter, or sequela. This injury code will continue to be coded until the condition is totally resolved without any sequela. When the patient returns for follow up the 7th character changes. The 7th character definitions for this category are:

  • A – Initial encounter for injury

Examples of active treatment are:

  • surgical treatment,
  • emergency department encounter, and
  • evaluation and treatment by a new physician.

  • D – Subsequent encounter for injury with routine healing
    Examples of subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.

Examples of subsequent care are:

  • cast change or removal,
  • removal of external or internal fixation device,
  • medication adjustment,
  • other aftercare and follow up visits following treatment of the injury or condition.

  • S – Sequela

“S” is for use for complications or conditions that arise as a direct result of a condition. When using 7th character “S”, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The “S” is added only to the injury code, not the sequela code. The 7th character “S” identifies the injury responsible for the sequela. The specific type of sequela (e.g. contracture after fracture) is sequenced first, followed by the injury code.

Coding

ICD-9-CM Diagnosis Codes
836.0 Tear of medial cartilage or meniscus of knee, current
719.06 Effusion, knee

ICD-10-CM Diagnosis Codes
S83.2Ø6A Unspecified tear of unspecified meniscus, current injury, right knee, initial encounter
M25.461 Effusion, knee, right

Scenario 4: Right Shoulder Pain & Possible Rotator Cuff Tear

Scenario Details

Chief Complaint

  • Right shoulder pain.

History

  • This 45 year old female presents today for right shoulder pain. This has been ongoing and patient cannot describe any injury prior to the pain beginning.
  • Patient rates the pain at 7/10. Describes pain as constant and achy and awakens her at night. The pain is also exacerbated by throwing, lifting, and carrying activities but not overhead activities, weight-bearing activities or reaching. She complains of weakness but no instability, swelling, clicking, numbness, catching, tingling, or neck pain.
  • Current medications: Ibuprofen for shoulder pain.
  • 16 point review of systems negative.

Exam

  • Neurovascular intact x 4 extremities; no lymph nodes palpated.
  • No pain or weakness with internal rotation and no weakness with external rotation. No pain over the acromioclavicular joint, the anterior joint line, the SC joint, or acromion.
  • There is pain over the greater tuberosity, proximal biceps, and scapula, and pain and weakness with resisted scaption and pain with external rotation.
  • Pain over anterolatereral shoulder. Pain increases with AROM. Decreased active elevation, normal passive ROM to right upper extremity.
  • The patient has negative testing with Jobe relocation test, Apprehension testing, load and shift testing, belly press testing, lift off test, and Yergason test. Positive testing with Obriens test, Mayo Sheer test, posterior labral provocation, Neer impingement test, Hawkins Kennedy impingement test, and Speeds test.
    Assessment and Plan
  • 4-view x-ray series of the right shoulder shows calcific deposit. No fracture or dislocation. There is acromioclavicular joint post-traumatic osteoarthritis, post glenoid bone fragment. Injury cause unknown.
  • Tendinitis due to calcification
  • Will order MRI for the right shoulder to rule out a possible rotator cuff tear. See patient next week in follow up.
  • Right shoulder pain; declined prescription for pain medication. She will continue to use ice and OTC pain medication.

Other Impacts

Post traumatic osteoarthritis cannot be assumed because of any injury and arthritis that follows. The documentation from the provider must include “post-traumatic” to code to M19.111 category. Calcification of joint is included in the M75 category in ICD-10-CM so an additional code in ICD-10-CM is not required.

Summary of ICD-10-CM Impacts

Clinical Documentation

  1. In ICD-10-CM, osteoarthritis codes are divided by specific location, laterality, and types. The codes associated with osteoarthritis in the “other” joints block (other than hip, knee, and first carpometacarpal joint) include primary, posttraumatic, secondary, and unspecified.
  2. Pain may be considered integral to the underlying post-traumatic osteoarthritis, and thus is not coded separately as a symptom.

Coding

ICD-9-CM Diagnosis Codes
715.31 Osteoarthrosis, localized, but unspecified as to primary or secondary, shoulder region
726.11 Calcifying tendinitis of shoulder
719.81 Calcification, joint, shoulder
ICD-10-CM Diagnosis Codes
M19.111 Post-traumatic osteoarthritis, right shoulder
M75.31 Calcific tendinitis of right shoulder

Scenario: Cervical Disc Disease

Scenario Details

Chief Complaint

  • “My neck hurts and I have a tingling pain sensation going down my right arm.”

History

  • Patient is a 68 year-old male with history of neck pain that has been worsening over the last two years. Recently, he has experienced some numbness and a painful tingling sensation in his right arm going down to his thumb. No other symptoms or pertinent medical history.

Review of Systems, Physical Exam, Laboratory Tests

  • Review of systems is negative except for the neck pain and sensations in his right arm described above. No history of acute injury to neck or arm.
  • Physical exam is normal except for neurological exam of the right upper extremity, which reveals slight decrease to sensation in the thumb and forefinger region of the hand in the C6 nerve root distribution. No evidence of weakness in the muscles of the arm or hand.
  • MRI scan of the neck shows degenerative changes of the C5-6 disc with lateral protrusion of disc material. No other abnormalities noted.

Assessment and Plan

  • Cervical transforaminal injection at C5-6

Summary of ICD-10-CM Impacts

Clinical Documentation
- Subcategory M50.1 describes cervical disc disorders. M50.12 Cervical disc disease that includes degeneration of the disc as a combination code. The 5th character differentiates various regions of the cervical spine (high cervical C2-3 and C3-4; mid-cervical C4-5, C5-6, and C6-7; cervicothoracic
C7-T1 and the associated radiculopathies at each level). This is a combination code that includes the disc degeneration and radiculopathy

Coding

ICD-9-CM Diagnosis Codes
722.0 Cervical disc displacement without myelopathy
722.4 Degeneration of cervical intervertebral disc

ICD-10-CM Diagnosis Codes
M50.12 Cervical disc disorder with radiculopathy, mid-cervical region

Scenario: Struck by Car

Scenario Details

Chief Complaint

  • “I was crossing the street and got hit by a car. My right leg is broken and my left wrist hurts.”

History

  • Patient is a 24-year-old male brought to the Emergency Department after being struck by a car while crossing the street. He denies any previous medical diseases or surgical procedures.

Review of Systems, Physical Exam, Laboratory Tests

VSS and Physical Exam are within normal limits with the following exceptions:

  • RLE: open fracture of the mid-shaft region of the femur. Wound is approximately 15 cm in length and the bone fragments show injury to bone and periosteum (Gustilo Type IIIB); at least three fragments are visible. No apparent nerve or vascular injuries are noted.
  • LUE: skin intact over entire extremity. There is obvious deformity of the wrist, which is painful to palpation. Neurological and vascular exam of the hand is intact.
  • X-rays: comminuted mid-shaft fracture of the right femur. There is a transverse fracture of the distal left radius just proximal to the wrist joint with dorsal displacement of the distal fragment (Colles’ fracture). All other x-rays are normal.

Hospital Course

  • The patient was admitted to the hospital and taken directly to the operating room for initial treatment, including debridement and irrigation of the right open fracture and splinting of the left wrist. On the second hospital day, the patient was again taken to the operating room for definitive treatment of the both fractures by open reduction and internal fixation (ORIF) techniques.

Assessment and Plan

  • Open comminuted fracture of the right femur, mid-shaft treated by ORIF
  • Closed transverse fracture of the distal left radius treated by ORIF
  • Injuries caused by vehicle-pedestrian accident

Summary of ICD-10-CM Impacts

Clinical Documentation

  • When one or more fractures occur and different surgical procedures are performed, all of the first procedures are coded as initial encounter. The 7th character is not influenced by the order of the surgical procedures.
  • When multiple surgical procedures are performed, although the codes for each injury are different, the reason is the same. In this case, the fracture of the femur and wrist were both caused by being hit by a car.
  • Surgical treatment is considered “active” treatment or initial treatment even if it is not the first surgical procedure for the injury being treated.
  • Open fractures are classified by their Gustillo type with 7th characters specific to type I, II, IIIA, IIIBB or IIIC.
  • The definitions of initial and subsequent are found in Volume 2 guidelines under Chapter 19.

7th character “A”, initial encounter is used while the patient is receiving active treatment for the condition. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician.

7th character “D” subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.

Examples of subsequent care are: cast change or removal, an x-ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition.

  • The ICD-10 code V03.10xA illustrates the use of placeholder “x” when a 7th character is required, but the code only progresses to a 5th character level. In this example then the “x” placeholder is put into character space position 6 and then the 7th character for episode is added last. In the chart you can see the possibilities of coding future encounters for this injury:

Injury Code

S72.351C Fracture, comminuted shaft of femur, initial encounter for treatment of open fracture type IIIB
S72.351F Fracture, comminuted shaft of femur, subsequent encounter for treatment of open fracture type IIIB with routine healing
S72.351N Fracture, comminuted shaft of femur, subsequent encounter for treatment of open fracture type IIIB with nonunion

External Cause Code

V03.10xA Pedestrian, on foot, injured in collision with car, pick-up truck, or van in traffic accident, initial encounter
V03.10xD Pedestrian, on foot, injured in collision with car, pick-up truck, or van in traffic accident, subsequent encounter
V03.10xS Pedestrian, on foot, injured in collision with car, pick-up truck, or van in traffic accident, sequela

  • Report the external cause codes in ICD-10-CM.
    Include when documented:
  • The external cause for the codes
  • What the person was doing when they were injured (when documented)
  • Location of the accident (when documented)
  • The status of the patient such as student, volunteer, at work, and etc. (when documented)

The “how it happened” external cause code should never be a first-listed code on a claim. This code should be used on all additional claims for this injury following the same guideline for the 7th character with the same definition of initial versus subsequent or sequela.

Coding

ICD-9-CM Diagnosis Codes
821.11 Fracture, open shaft of femur
813.41 Fracture, Colles’
E18.7 Accident, Motor vehicle involving collision with pedestrian injuring pedestrian
E849.5 Accident, occurring in street

ICD-10-CM Diagnosis Codes
S72.351C Fracture, comminuted shaft of femur, initial encounter for treatment of open fracture type IIIB
S52.532A Colles’ fracture of left radius, initial encounter for closed fracture
V03.10xA Pedestrian, on foot, injured in collision with car, pick-up truck, or van in traffic accident, initial encounter
Y92.410 Unspecified street and highway as the place of occurrence of the external cause

Scenario: Fracture

Scenario Details

Chief Complaint

•“I fell and hurt my right hip.”

History

  • Patient is a 74-year-old male who tripped over a rug at home, fell and had immediate pain in his right hip. He was transported to the Emergency Department by ambulance. In addition to his hip pain, he has a history of high blood pressure currently treated with Zaroxolyn and Lisonopril. He admits that he has been in the habit of cutting his BP pills in half to save money on refills. He also has a history of a myocardial infarction several years ago without any current manifestations.

Review of Systems, Physical Exam, Laboratory Tests

  • Patient denies any symptoms other than hip pain; specifically denies any recent history of chest pain, arm pain, epigastric pain or shortness of breath
  • BP on admission to the ED: 180/95
  • X-ray: Right intertrochanteric hip fracture; no evidence of other bony injury
  • EKG: evidence of old myocardial infarction; no evidence of recent myocardial injury

Treatment in ED

  • Patient given IV medications for pain (morphine 1-2 mg IV titrated for relief)
  • BP after IV medication: 165/90

Assessment and Plan

  • Admit to hospital
  • NS IV at 75 cc/hour
  • Pain medications: morphine 1-2 mg IV prn
  • NPO for surgery
  • Orthopedic surgery and anesthesia consults

Summary of ICD-10-CM Impacts

Clinical Documentation

  • Coding fractures as specifically as possible code to location, left versus right, and displaced or nondisplaced, open or closed (7th character) and initial, subsequent, or sequela (7th character)
  • NOTE that for S72 codes there are 16 different letters for the 7th character. Not only are they divided by type of encounter, but also open or closed, healing, non-union and type of open or closed fracture. Therefore, subsequent encounters may be any of the following codes for a closed fracture:
  • S72.141G (Closed, delayed healing) W18.09xB
  • S72.141K (Closed, non-union) W18.09xB
  • S72.141P (Closed mal-union) W18.09xB
  • Coding the mechanism of injury and place where the injury occurred from Index of External Causes that is found in Volume 3. In this index the key word is “Fall” is how the accident happened. These accident codes will always have a 7th character that refers to an initial, subsequent, or sequela encounter.
  • This accident code will align with the actual injury code until resolved. The 7th character will then in subsequent encounters change to “subsequent” or “sequela” depending on the documentation in subsequent encounters. The “how it happened” external cause code should never be a first-listed code
    on a claim per ICD-10-CM coding guidelines.

Example:

Injury Code
S72.141A Displaced fracture, right femur, initial encounter
S72.141D Displaced fracture, right femur, subsequent encounter
S72.141S Displaced fracture, right femur, sequela encounter

External Cause Code
W18.09xA Striking against other object with subsequent fall, initial encounter
W18.09xD Striking against other object with subsequent fall, subsequent encounter
W18.09xS Striking against other object with subsequent fall, sequela encounter

Fracture Code for Subsequent Encounters
S72.141G Displaced fracture, right femur, closed fracture delayed healing
S72.141K Displaced fracture, right femur, closed fracture with nonunion
S72.141P Displaced fracture, right femur, closed fracture with malunion

External Cause Code
W18.09xD Striking against other object with subsequent fall, subsequent encounter
W18.09xS Striking against other object with subsequent fall, sequela encounter
W18.09xS Striking against other object with subsequent fall, sequela encounter

  • The code W18.09xD should be used on all additional claims for this injury following the same guideline for the 7th character with the same definition of initial versus subsequent or sequela.
  • Additional external cause codes should be used when documented for:
  • What the person was doing when they were injured (when documented)
  • Location of the accident (when documented)
  • The status of the patient such as student, volunteer, at work, and etc. (when documented)
  • Coding relevant co-morbid conditions such as patient’s HTN
  • Coding medication non-compliance (underdosing) from the Table of Drugs & Chemicals found in Volume 3. Go to the Table and along the left hand side located the drug name and if drug name is not found then search for the drug class. Then move across the columns to “underdosing” column. Move
    to the Tabular List (Volume 1) for the 7th character for initial, subsequent or sequela. The 7th character is found at the beginning of the category T46 and T50.
  • Each medication that was under-dosed should be coded separately in ICD-10-CM.
  • Use adjunct Z code for intentional underdosing after the underdosing as it is included in the documentation. The instruction for the use of these Z codes are found in the Tabular List (Volume 1) at the beginning of the poisoning, adverse effect and underdosing section above code T36.
  • See the snapshot photo of this instruction below next to “Use additional code (s) to specify”

Other Impacts

ICD-10 has under-dosing code with each drug coded separately while ICD-0-CM does not have underdosing codes.

Coding

ICD-9-CM Diagnosis Codes
820.21 Femur fracture, closed, intertrochanteric section
E885.9 Fall from other slipping, tripping or stumbling
E849.0 Accident occurring at home
401.9 Essential hypertension, unspecified
412 Old myocardial infarction
V15.81 History of non-compliance with treatment

ICD-10-CM Diagnosis Codes

S72.141A Displaced intertrochanteric fracture of the right femur, initial encounter for a closed fracture (Note: fractures not indicated as displaced or nondisplaced are coded as displaced; fractures not indicated as open or closed are coded as closed) (See note below S72 category in the Tabular List

of ICD-10-CM)
W18.09xA Striking against other object with subsequent fall, initial encounter
Y92.009 Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause
I10 Hypertension
I25.2 Old myocardial infarction
T46.4x6A Underdosing of angiotensin-convertingenzyme inhibitors, initial encounter
T50.2x6A Underdosing of carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, initial encounter

Z91.120 Intentional under dosing of medication regimen due to financial hardship