Orthopedics Tips for Clinical Documentation
Clinical documentation tells a patient?s story. Specifying anatomical location and laterality required by ICD-10 is easier than you think. This detail reflects upon how physicians and clinicians communicate and to what they pay attention. It is a matter of ensuring that the information is captured in your clinical documentation. There are three main categories of changes in ICD-10-CM, Definition changes, Terminology Differences and Increased Specificity. For orthopedics, the focus is mostly on increased specificity. Over one third of the expansion of ICD-10 codes is due to the addition of laterality: Left, Right, or Bilateral. Physicians and other clinicians likely already note the laterality when evaluating the clinically pertinent anatomical site(s).
For Eg:
? M21.722 Unequal limb length (acquired), left humerus
? M25.561 Pain in right knee
? M25.562 Pain in left knee
? S72.344A Nondisplaced spiral fracture of shaft of right femur, initial encounter for closed fracture
The main areas for Orthopedics:
? Fractures
? Arthritis
? Injuries
FRACTURES:
The following parameters must be included while documenting fractures:
1. Type
? Open
? Closed
? Pathological
? Neoplastic disease
? Stress
2. Pattern
? Comminuted
? Oblique
? Segmental
? Spiral
? Transverse
3. Etiology to document in the external cause codes
4. Encounter of care:
? Initial
? Subsequent
? Sequelae
5. Healing status, if subsequent encounter :
? Normal healing
? Delayed healing
? Nonunion
? Malunion
6. Localization
? Shaft
? Head
? Neck
? Distal
? Proximal
? Styloid
7. Displacement :
? Displaced
? Non displaced
8. Classification:
? Gustilo-Anderson
? Salter-Harris
9. Any complications, whether acute or delayed:
? Direct result of trauma sustained In addition, depending on the circumstances, it may be necessary to document intra-articular or extra-articular involvement.
? For certain conditions, the bone may be affected at the proximal or distal end. Though the portion of the bone affected may be at the joint at either end, the site designation will be the bone, not the joint.
ICD-10 Code Examples:
? S52.521A Torus fracture of lower end of right radius, initial encounter for closed fracture
? S52.521D Torus fracture of lower end of right radius, subsequent encounter for fracture with routine healing
? S42.021K Displaced fracture of the shaft of right clavicle, subsequent for fracture with nonunion.
ARTHRITIS
There are specific codes for primary and secondary arthritis in ICD-10-CM. Within the secondary arthritis codes there are specific codes for post-traumatic osteoarthritis and other secondary osteoarthritis. For secondary osteoarthritis of the hip there is also a code for dysplastic osteoarthritis.
ICD-10 provides more options for the coding osteoarthritis related encounters, including:
? Generalized forms of osteoarthritis or arthritis where multiple joints are involved.
? Localized forms of osteoarthritis with more specificity that includes primary versus secondary types, subtypes, laterality, and joint involvement.
The type, location, and specific bones and joints (multiple sites if applicable) involved in the disease must be specified.
In addition, describe any related underlying diseases or conditions.
ICD-10 Code Examples:
? M19.041 Primary osteoarthritis right hand
? M19.241 Secondary osteoarthritis, right hand
? M05.432 Rheumatoid myopathy with rheumatoid arthritis of left wrist.
INJURIES
When documenting injuries,the following points must be included:
1. Episode of Care
? Initial
? Subsequent
? Sequelae
2. Injury site
3. Etiology :
? Sports
? Motor vehicle crash
? Pedestrian,
? Slip and fall
? Environmental exposure
4. Place of Occurrence :
? School
? Work