Documentation opportunities abound in ICD-10-CM Chapter 13 (musculoskeletal system).
The official ICD-10-CM Coding Guidelines provide us with plenty of instructions.
The guidelines include instructions on coding for site and laterality. Site represents either the bone or joint or muscle involved. For some conditions where more than one bone, joint or muscle is usually involved such as osteoarthritis there is a multiple site code. When no multiple site code is available coders should use codes to indicate the different sites involved.
Bone vs. joint: For certain conditions, the bone may be affected at the upper or lower end. Though the portion of the bone affected may be at the joint, the site designation will be the bone, not the joint.
Acute traumatic vs. chronic or recurrent conditions: The guidelines define these terms and provide coding instructions. If the musculoskeletal condition is from a previous injury or trauma or is recurrent, report a code from Chapter 13. Code any current acute injury with the appropriate injury code from chapter 19. If you cannot determine whether the injury is acute or traumatic from the documentation in the record, query the physician.
Coding pathological fractures: Pathologic fractures will require a seventh digit extension to identify episode of care. Use seventh character A as long as the patient is receiving active treatment. Active treatment is defined as:
- Surgical treatment
- ED encounter
- Evaluation and treatment by a new physician
Report seventh character D for encounters after the patient has completed active treatment. The other seventh characters listed under each subcategory in the Tabular List are to be used for subsequent encounters for treatment of problems associated with healing such as malunion, nonunion, and sequelae.
Osteoporosis: The official coding guidelines instruct coders to report codes from category M81- for osteoporosis without pathological fracture. Report these codes for patients with osteoporosis who do not currently have a pathologic fracture due to osteoporosis even if they have had one in the past.
For history of osteoporosis fractures use code Z87.31 (personal history of osteoporosis fracture). This should follow the code from M81-.
For patients with osteoporosis with current pathological fracture at the time of the encounter, use codes from M80-. The codes under M80 identify the site of the fracture. Use a code from M8- for any patient with known osteoporosis who suffers a fracture, even if the patient had a minor fall or trauma, if that fall or trauma would not usually break a normal healthy bone.
Codes for gout have been moved from Chapter 3 (endocrine, nutritional, and metabolic diseases) to Chapter12.
Key Documentation elements for fractures
- Fracture codes require documentation of the type of fracture as displaced or non-displaced
- More specific information is required on the fracture type. For example, codes for fracture of the surgical neck of the humerus are specific as to whether the fracture is a two-, three-, or four-part fracture.
- Seventh characters are required to identify the episode of care and whether the fracture is open or closed.
- Seventh characters also further classify open fractures using the Gustilo-Anderson open fracture classification system, which identifies fractures are Type I, II, IIIA, IIIB and IIIC.