Ortho
- Ch 6: Pain Nervous System G00-G99
- Ch 13: M/S Fracture M00-M99
- Ch 19: Injury/Burns/Wounds/Poisoning S00-T98
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
Additional Resources
Coding for ICD-10-CM: More of the Basics MLN Connects Video
For more information contact the AMA.