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Ortho

Ch 6: Pain Nervous System

ICD-9-CM
  •  Type
  •  Site

Ch 6: Pain Nervous System

ICD-10-CM Requirements

General Documentation:

  •  Type of pain:
    – Acute or chronic
    – Post-procedural (specify procedure)
    – Due to trauma
    – Neoplasm related (specify neoplasm and site)
  •  Site specificity, when applicable
  •  Laterality (right, left, bilateral), when applicable
  •  Dominant or Non-dominant side, when applicable

Chronic Pain:

  •  Central pain syndrome and Chronic pain syndrome are different than the term ‘chronic pain’ and will be coded based on your specific documentation.

Migraine, document:

  •  With or without aura
  •  Intractable or not intractable
  •  With or without status migrainosus

Epilepsy, document:

  •  Localization related or generalized
  • Intractable or not intractabl
  • With or w/o status epilepticus

-Limited to breakdown of skin
– With fat layer exposed
– With necrosis of muscle
– With necrosis of bone

Ch 6: Pain Nervous System

Notes

“Pain” is also included in other chapters based on specific documentation (site, not specified as acute or chronic).

Ch 13: M/S Fracture

ICD-9-CM
  • Site
  • Late Effect

Ch 13: M/S Fracture

ICD-10-CM Requirements

General Documentation:

  • Anatomical Site, when applicable (bone, join or muscle involved)
  •  Laterality (left, right, bilateral), when applicable
  •  Chronic, recurrent or healed musculoskeletal conditions

Fracture, document:

  •  Location (specify site of the fracture, e.g. hip fracture – subtrochanteric fracture of right femur)
  •  Late Effect
  •  Type of fracture:
    – Fatigue
    – Stress
    – Pathological
  •  Laterality
  •  Encounter type:
    – Initial
    – Subsequent (specify routine or delayed healing, non-union, malunion)
    – Sequela

Osteoarthritis, document:

  •  Type:
    – Primary (wear and tear)
    – Secondary (caused by other condition)
    – Post-traumatic

Gout, document:

  •  Acute or chronic (with or without tophus)
  •  Idiopathic
  •  Lead-induced
  •  Drug-induced
  •  Due to renal impairment (specify renal disease)
  •  Other secondary gout (specify associated condition)

Ch 13: M/S Fracture

Notes

Fatigue fractures and collapsed vertebra will require a 7th character:

  • A – Initial encounter
  • D – Subsequent with routine healing
  • G – Subsequent with delayed healing
  • S – Sequela (complications, or conditions – i.e. scars)

Stress and Pathological fractures will require a 7th character:

  • A – Initial encounter
  • D – Subsequent with routine healing
  • G – Subsequent with delayed healing
  • K – Subsequent with non-union
  • P – Subsequent with malunion
  • S – Sequela (complications, or conditions – i.e. scars)

Ch 19: Injury/Burns/Wounds/Poisoning

ICD-9-CM

•Location/Site
•Injury
•Type
•Depth
•Percentage

Ch 19: Injury/Burns/Wounds/Poisoning

ICD-10-CM Requirements

General Documentation:

  • Location/site
  •  Laterality
  •  Sequence most serious injury as determined by the provider
  •  Superficial injury/abrasions or contusions should be specified if associated with more severe injuries of the same site.
  • Injury with damage to nerve/blood vessels: document primary injury, followed by nerves and/or blood vessels. (If the primary injury is to the nerve/blood vessel code as primary.)

Fractures, document:

  •  Location (specify site of the fracture, e.g. hip fracture – subtrochanteric fracture of right femur)
  •  Open or Closed
  • Late Effect
  •  Type:
    – Displaced or non-displaced
  •  Laterality
  •  Gustilo classification system (specify classification) of open fractures
  •  Encounter type:
    – Initial (during active treatment)
    – Subsequent (i.e. specify routine or delayed healing, non-union, malunion)
    – Sequela

Burns, document:
Distinguish between ‘burns’ and ‘corrosions’

  • If thermal burn, specify heat source (i.e. electricity or radiation)
  • Specify if due to chemicals.

Wounds, document:

  • Location/site
  • Depth
  • Type:
    – Bite
    – Laceration
    – Puncture
  • With or without foreign body

Poisoning:

  • Identify define Drug or Chemical
  • Specify: Adverse effect, Poisoning, Under-dosing or Toxic effects

Ch 19: Injury/Burns/Wounds/Poisoning

Notes

Most codes may require a 7th
character for encounter type. Burns:

  • Sequence code to highest degree of burn(s).
  • Non-healing burns coded as Acute Burn (Necrosis of non- healed burn coded as non- healed burn).
  • Infected burn site, use additional code for infection.
  • Burns are classified by degree/depth, extent and age

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