How to Code Joint Dislocation under ICD-10-CM
Joint Dislocation(s) are injuries that force the ends of your bones out of position. The cause is often a fall or a blow (for instance, sustained while playing a contact sport).
Joints that can dislocate include:
- Ankles
- Knees
- Shoulders
- Hips
- Elbows
- Jaw
- Fingers
- Toes
Complications of a joint dislocation may include:
- Tearing of the muscles, ligaments and tendons.
- Nerve or blood vessel damage in or around your joint.
- Susceptibility to re-injury.
- Development of arthritis in the affected joint.
Surgery may be required to repair the tissues, if ligaments or tendons that support the injured joint have been stretched, torn or if nerves or blood vessels surrounding the joint have been damaged.
Code Selection and Documentation:
Good clinical documentation should indicate the location of the dislocation including laterality (right or left) and the extent of dislocation:
The extent of the dislocation may be defined using several methods:
- Partial of incomplete dislocation of joint – Subluxation.
- Complete dislocation of the joint, also known as luxation of the joint – Dislocation.
- Dislocations of certain joints are further classified by the extent based upon percentage of the dislocation – Percentage.
Dislocations may further be defined by positioning:
- The end of the bone is displaced to the anterior, medial, and slightly inferior to its normal anatomic position – Anterior.
- The end of the bone is displaced posterior to the joint and its normal anatomic position – Posterior.
- The end of the humerus is forced against the acromion causing the arm to lock in an upward and backward position – Inferior.
- The end of the bone is displaced outwardly (laterally) to the joint and its normal anatomic position -Laterally.
ICD-10-CM Codes:
- S03 Dislocation and sprain of joints and ligaments of head
- S13 Dislocation and sprain of joints and ligaments at neck level
- S23 Dislocation and sprain of joints and ligaments of thorax
- S33 Dislocation and sprain of joints and ligaments of lumbar spine and pelvis
- S43 Dislocation and sprain of joints and ligaments of shoulder girdle
- S53 Dislocation and sprain of joints and ligaments of elbow
- S63 Dislocation and sprain of joints and ligaments at wrist and hand level
- S73 Dislocation and sprain of joints and ligaments of hip
- S83 Dislocation and sprain of joints and ligaments of knee
- S93 Dislocation and sprain of joints and ligaments at ankle, foot, and toe level
The encounter should also be documented such as:
- Initial encounter,
- Subsequent encounter or
ICD-10-CM includes (and requires) seventh characters extensions for most categories in chapter 19. Most categories in chapter 19 have three extensions, with the exception of fractures:
- Afor initial encounters: This means the patient is receiving active medical treatment.
- Dfor subsequent encounter: This means the patient is receiving routine care after completed active treatment.
- S to indicate a sequela of the condition. The sequela are the residual effects (condition produced) after the acute phase of a illness or injury has terminated
It must be remembered in ICD-10-CM, the seventh character must always be the seventh character in the data field. A placeholder X must be used to fill any empty characters.