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Why does diagnosis coding accuracy make a difference? When submitting a claim to any payor for reimbursement, the diagnosis code establishes the medical necessity for the procedure or service performed, and the documentation must support the condition(s) managed. Some Medicare National and Local Coverage Determinations are not only driven by the CPT code but the diagnosis (ICD-10-CM) code as well. Diagnosis(es) codes reported are also valuable as they contribute to research outcomes and clarify the severity of a condition.
The ICD-10-CM codes and guidelines have been released, and there are 252 new codes with 13 code revisions and 36 code deletions. Most ICD-10-CM codes for Orthopedics are located in the musculoskeletal system in Chapter 13 and Chapter 19 (Chapter 19- Injury, Poisoning, and Certain Other External Causes (S00-T88) of ICD-10-CM. Here are the highlights from Chapters 13 and 19 of ICD-10-CM.
New codes in Chapter 13 that are added under Category M51.36 (Other intervertebral disc degeneration, lumbar region) to include a sixth character M51.360-M51.369 for other intervertebral disc degeneration, lumbar region to identify location and type of pain.
Under Category M51.37 (Other intervertebral disc degeneration, lumbosacral region), a sixth character was added to identify type and anatomic location of pain to include M31.370-M31.379. Excludes notes were added to Sciatica (M54.3), M54.4 (Lumbago with sciatica) and M54.5 (low back pain) to exclude codes in Category M51.36 and M51.37.
A new code was added (M62.85) to report dysfunction of the multifidus muscles of the lumbar region.
New codes were added under category M65 to report unspecified synovitis and tenosynovitis based on laterality of the shoulder (M65.90-M65.919), upper arm (M65.921-M65.929), forearm (M65.931-M65.939), hand (M65.941-M65.949), thigh (M65.951-M65.929), lower leg (M65.961-M65.969) and ankle and foot (M65.971-M65.979). The addition of these codes will add further specificity such as right left, unspecified. Two additional diagnosis code were added in this category which includes M65.98 Unspecified synovitis and tenosynovitis, other site and M65.99 Unspecified synovitis and tenosynovitis, multiple sites.
In Chapter 19 of ICD-10-CM there were several codes added and revised but one code that might me of importance to Orthopedics is new code T81.328 (Disruption or dehiscence of closure of other specified internal operation (surgical wound) which includes:
- Disruption or dehiscence of closure of muscle or muscle flap (other than abdominal wall muscle)
- Disruption or dehiscence of closure of tendon or ligament
- Disruption or dehiscence of closure of superficial or muscular fascia
A cross-reference was added to T81.4 (Infection following a procedures) to code also a code from T81.32-).
The unspecified code T81.329 has been added to report a deep disruption or dehiscence of operation wound, unspecified.
Just a reminder: the sixth character, “1,” is right, the sixth character, “2,” is left, and if the sixth character is “9,” it is unspecified. Payors expect that if the code contains laterality, it is reported with the correct diagnosis code. If you report an unspecified site, a payor might deny the claim based on lack of specificity.
Lastly, two new social determinants of health codes were added in Chapter 21 of ICD-10-CM to report insufficient health insurance coverage (Z59.71) and insufficient welfare support (Z59.72).
It is important to review the ICD-10-CM guidelines on an annual basis as well as all diagnosis code changes that may affect your practice.
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