MS Diagnostic CodingMS Diagnostic Coding

Irene Mueller, EdD, RHIAIrene Mueller, EdD, RHIA

MHAMHAMay 21, 2009May 21, 2009

Objectives – First HourObjectives – First Hour

• Traumatic/Repetitive Stress– Fx (Traumatic), non-

unions, mal-unions – Dislocations– Sprains/Strains– Intervertebral disc

disorders – Bunions– Bursitis– Knee (Meniscus/ACL)– Carpal Tunnel

• Pathologic/Congenital– Arthritis (Osteo,

Rheumatoid, Lyme disease)

– Gout– Osteoporosis – Bone/Connective tissue

neoplasms – Congenital (Marfan)

ObjectivesObjectives

• 2nd hour

• ICD -9-CM– Chapter 13 and Chapter 17– V codes, E codes

• Resources

MS DisordersMS Disorders

• Trauma (major cause)

• Rheumatic

• Inflammatory

• Degenerative

Bone/Joint DisordersBone/Joint Disorders

• Traumatic– Fractures– Dislocation– Sprain vs Strain– Whiplash– Slipped disc– Bunions– Bursitis– Carpal Tunnel Syndrome

• Pathologic– Fxs– Osteoarthritis– Rheumatoid arthritis– Gout– Pseudogout– Rickets/Osteomalacia– Osteoporosis– Lyme Disease– Nonunion/Malunion– Neoplasms

FracturesFractures

• Caused by stress on bone– Trauma– Severe muscle spasm– Bone disease

• Classified by nature of fx– Mechanism of injury

Fx EtiologiesFx Etiologies

• Traumatic– MVAs

– Falls

– Assaults

• Pathologic– Spontaneous fxs

– Neoplasms

– TB of bone

– Paget disease• Osteitis

Deformans

– Osteoporosis

S&S of FxsS&S of Fxs

• Pain

• Edema, tenderness, discoloration

• Inability to move body part

• Deformity of body part (sometimes)

• Bone protruding through skin

• Numbness/tingling in joint

Open/Closed FxOpen/Closed Fx

• Closed (Simple, comminuted, depressed)– Overlying skin is intact

• Open (Compound, infected, missile, puncture, w/FB)– Overlying skin is NOT intact– An open wound communicates with the bone

– http://www.immediateactionservices.com/femurfractureopen.jpg_jpg.html

Fx descriptionsFx descriptions

• Eponyms (Names)– Ex: Colles fx

• Fx of distal head of radius/ulnar styloid

– Ex: Le Fort fx• Bilateral horizontal fx of

maxilla• Common in driver in MVA

– Ex: Pott fx • Distal end of fibula

• Locations– Ex: Fx of humerus

– Proximal, shaft, distal

DislocationsDislocations

• S&S– Misshapen joint, extreme pain– Rapid edema, ecchymosis, immobility– Possible damage to tissues, nerves, vessels– Can result in distal paralysis, osteoarthitis

• Etiology– Trauma – Congenital weakness– Ehlers-Danlos syndrome

http://www.immediateactionservices.com/dislocatedpatella_jpg.html

Sprains and StrainsSprains and Strains• Sprain

– Acute partial tear of ligament– 1st, 2nd, 3rd degree

• Strain– Injured muscle, tendon, or other tissue– Caused by overuse, overstretching

• Etiology– Acute – Chronic overuse (cumulative trauma)

• Sports/Occupation

S&S, Sprains/StrainsS&S, Sprains/Strains

• Pain, weakness, numbness, edema

• Stiffness, tenderness, soreness– Typical of chronic overuse

• Difficulty using

• Sprains can include damage to– Blood vessels/nerves– Ecchymosis and edema

WhiplashWhiplash

• Trauma to cervical vertebrae

• Etiology– Usu. Due to MVA – Head whipped backwards– Stresses neck spine and muscles

Slipped DiscSlipped Disc

• Herniated Nucleus Pulposus– Cartilage disc ruptures/protrudes– Puts pressure on nerves– Usu. Lumbar-sacral area

• Etiologies– Cumulative trauma (body mechanics)– Impact (fall, MVA)– Poor posture/aging

http://www.nlm.nih.gov/medlineplus/ency/imagepages/9700.htm

MyelopathyMyelopathy

• “any disease or disorder of the spinal cord or bone marrow”

• Spine– Myelopathy - Often results from compression– Caused by injury/pathology– Injury = spinal cord injury

BunionBunion

• Hallux Valgus– Enlarged local area of inner portion of

metatarsophalangeal joint of big (great) toe

• S&S– 2ndary inflamed bursa– Pain– Big toe moves over/under 2nd toe

• More common in women/girls• very_big_bunion.gif

BunionBunion

• Etiology– Associated w/ rheumatoid/osteo arthritis – Flatfoot– High-heels/poorly fitted shoes/Ballet– Familial tendency

BursitisBursitis

• Inflammation of a bursa– Calcifications & Adhesions (chronic)

• S&S– Tenderness (point)– Pain when moving– Flexion/extension limited– Edema– http://www.apmsurgery.com/sitebuilder/images/infrapatellar_bursitis-187x249.jpg

BursitisBursitis

• Etiology– Friction bet. Bursa and MS

(continual/excessive)– Gout, Rheumatoid arthritis– Infection (abrasion/puncture wounds)– Overuse

• Throwing, leaning, kneeling

Knee Knee

• Torn Meniscus (semi-lunar cartilage)– Medial (more frequent) and lateral in each knee– Usu. Caused by wear and tear

• Sports injuries

• S&S– Locking/giving way– Crepitation may be heard– Pain w/full extension– Full flexion may be difficult

Carpal Tunnel SyndromeCarpal Tunnel Syndrome

• Entrapment/Compression of Median Nerve

http://images.medicinenet.com/images/illustrations/carpal_tunnel.jpg

Carpal Tunnel SyndromeCarpal Tunnel Syndrome

• S&S– Pain more pronounced at night– Swelling of wrist/hand, “fluttering” of fingers– Shaking/moving wrist may bring relief (temp.)

• Etiology– Tendons w/in carpal tunnel become inflamed– Due to Repetitive overuse of hand/wrist/fingers– Pinching of median nerve

• Ergonomics can help in prevention

Pathologic Bone DisordersPathologic Bone Disorders

– Fxs– Osteoarthritis– Rheumatoid arthritis– Gout– Pseudogout– Rickets/Osteomalacia– Osteoporosis– Lyme Disease– Nonunion/Malunion– Neoplasms– Marfan Syndrome

Pathologic FracturesPathologic Fractures

• Common etiologies– Neoplasms– TB of bone– Paget disease– Osteoporosis

• “Spontaneous” fxs – ALWAYS pathologic– insufficiency fx, nontraumatic fx, or nontraumatic compression fx

= pathologic fx• “Compression” fx – be careful!!!

– Can have traumatic OR pathologic etiology

Mal-union/Non-unionMal-union/Non-union

• Malunion – healed fx with poor alignment

• Non-union - failure of the fragments of a broken bone to knit together (no healing)– DM– Renal disease– Smoking slows bone healing

http://img.tfd.com/vet/thumbs/gr257.jpg

ArthritisArthritis• Inflammation of joints, breakdown of

cartilage (250+ types)

• S&S (common to all types)– Inflammation– Swelling– Pain– Stiffness– Mobility problems

• Can be Primary, often 2ndary

OsteoarthritisOsteoarthritis

– By far the most common type– Degenerative Joint Disease, usu. older pts

• Degenerative cartilage/hypertrophic bone

– Degenerative or hypertrophic arthritis, polyarthritis

– “Wear and Tear”- Arthritis– Joints – large, weight-bearing usually affected

• Hips, knees, spine – fingers, wrists, elbows, ankles

ArthritisArthritis

• Arthritis due to Infection– Gonococcal arthritis– Septic arthritis

• Bacterial, non-gonorrhea

– Lyme disease (Tertiary)• spirochete bacterium

– Viral (Temporary, in most cases)• Hepatitis B/C• Mumps, Rubella

http://knol.google.com/k/-/-/Pzjo3lpf/DH8Xuw/Figure%2067-2.jpg

ArthritisArthritis

• Autoimmune types– Psoriatic arthritis – Rheumatoid arthritis

• Autoimmune disease• Chronic, inflammatory, systemic• Severe form of arthritis, deformity/disability• Systemic – heart, vessels, layers of skin• Joints – fingers, wrists, knees, ankles, toes

http://www.csmc.edu/images/354031_adv_rheumatoid_arthritis-2sm.jpg

ArthritisArthritis

• Metabolic disorders– Gout

• Uric acid buildup, crystals in joint (Tophi)• Kidney stones• 2ndary to Chemotx for malignancies• Purines in diet (meats, wines, beer)

– Pseudogout• Calcium phosphate buildup

http://www.healthinplainenglish.com/health/musculoskeletal/gout/gout-surgery.jpg

ArthritisArthritis

• Post-Traumatic Arthritis– “Any traumatic injury to the joint, its ligaments

or supporting muscles makes the joint unstable. The increased stress on the joint cartilage may lead to arthritis.”

– http://global.smith-nephew.com/us/patients/Posttraumatic_arthritis_11517.htm

Lyme DiseaseLyme Disease

• Infectious - spirochete bacterium– Borrelia burgdorferi, B. afzelii (Europe)– 1975, Lyme, Conn– All 50 states, 5 continents– Hikers, campers

• S&S– Red, itchy rash, red circle center (target lesion)

• 50% of patients

– Arthritis-like symptoms– Paralysis, neuro, encephalitis, gastritis, carditis

• Lyme arthritis can occur acutely/chronicallyhttp://www.wesleykozinn-md.medem.com/medem/photos/s1802335_p401698_Erythema%20migrans.jpg

OsteoporosisOsteoporosis• Loss of normal bone

density• Most common

metabolic bone disease

• S&S– Loss of height– Spontaneous fxs– Pain can occur, but

usually not until fx occurs

• Risk factors– Female– Postmenopausal

• Lack of estrogen

– Small-boned– Northern European/Asian

background– Smoking– Family hx– Some meds (heparin)

• Increasing #s of men

Rickets vs. OsteomalaciaRickets vs. Osteomalacia

• Soft, flexible, deformed bones• Same disorder

– Rickets is term when occurs in children

• Etiology– Lack of/ineffective use of vitamin D

• Non-exposure to sun, renal diseases, malabsorption of D

• S&S– Fatigue, stiffness– Backaches– Muscle twitching/cramps– Fxs, bowed legs, chest deformity– Shortening of spine

Bone CancerBone Cancer

• Malignant (cancerous) tumor of the bone.

• Benign (noncancerous) bone tumors are more common than malignant ones.

• Malignant tumors that begin in bone tissue = primary bone cancer.

• Primary bone cancer is far less common than cancer that spreads to the bones (2ndary).

• Cancer that spreads to the bones from other parts of the body is metastatic cancer, and is named for the organ or tissue in which it began.

• The most common cancers that spread to the bone are – Breast – Kidney – Lung – Prostate

– Thyroid

Source: http://www.cancer.gov/cancertopics/factsheet/Sites-Types/bone

Common types of Common types of primary bone cancerprimary bone cancer

• Osteosarcoma arises from osteoid tissue– This tumor occurs most often in the knee and upper

arm • Chondrosarcoma begins in cartilaginous tissue.

– Chondrosarcoma occurs most often in the pelvis upper leg, and shoulder.

– Sometimes a chondrosarcoma has cancerous bone cells (osteosarcoma).

• The Ewing Sarcoma Family of Tumors (ESFTs), – usually occur in bone but can arise in soft tissue

(muscle, fat, fibrous tissue, blood vessels, or other supporting tissue).

– ESFTs occur mostly along the backbone and pelvis and in the legs and arms.

Marfan Syndrome Marfan Syndrome ((arachnodactyly)arachnodactyly)

• Dominant inherited disorder of connective tissue

• causes abnormalities of the eyes, cardiovascular system, and musculoskeletal system

• Named in 1896, gene id in 1991

• Dx: Four skeletal signs + at least one in another system

• Bones and Joints

• Long, thin fingers • Long arms & legs • Tall/thin body type • Curvature of spine

(scoliosis or kyphosis) • Chest sinks in (pectus

excavatum) OR• Chest sticks out/pigeon

breast (pectus carinatum) • Flexible joints • Flat feet • Teeth that are too crowded

Lab TestsLab Tests

• Handout

Break TimeBreak Time

ICD-9-CM Chapter 13ICD-9-CM Chapter 13

• Arthritis

• Pathologic Fractures

• Back disorders

ArthritisArthritis

• Can be Primary/Secondary– Dual Coding guidelines apply– Secondary (monarticular arthritis)

• Joints of one area, caused by internal/external injury or disease

• Lyme arthritis– w/current Lyme Disease

• 088.81 and 711.8x

– When late effect (chronic, acute phase past)• 139.8, 711.8x

OsteoarthritisOsteoarthritis• 715 codes, EXCEPT spinal• 720.0-724.9 for spinal involvement

• Primary axis for coding osteoarthritis– Generalized OR Localized (Dr. must state)– Localized INCLUDES bilateral involvement

• When localized, then subdivided– Primary 715.1x– Secondary 715.2x

• 715.3x for localized, primary/2ndary NOT specified• 715.8x for multiple sites, NOT specified as generalized• 716.9 = Arthritis with no other documentation

Other types of arthritisOther types of arthritis

• Rheumatoid - 714.0– Affects entire body

• Pyogenic – 711.0x– Due to infection– 5th digits indicates involved joints– Add’l code for causative organism

• Gouty arthritis – 274.0– Due to lead – 984.x

ExamplesExamples

• Arthritis of shoulder due to dicalcium phosphate crystals – 275.49, 712.11

• Charcot arthritis due to DM– 250.60, 713.5

• Reiter arthritis of hand– 099.3, 711.14

• Primary osteoarthritis of hip– ???

Pathologic FracturesPathologic Fractures

• Only Chapter-specific guidelines

• Path fx is Pr Dx ONLY – when pt admitted solely for tx of the fx

• Usually, code for underlying condition 1st

– Path fx code is additional code

Stress FracturesStress Fractures

• Due to repetitive force– May take days/weeks to show on x-ray

• Coded to – Tibia/fibula - 733.93– Metatarsals – 733.94– Other bone – 733.95– Femoral neck – 733.96 (10/1/08)– Femoral shaft – 733.97 (10/1/08)– Pelvis – 733.98 (10/1/08)

Acute pathologic Fxs vs. AftercareAcute pathologic Fxs vs. Aftercare

– 733.1 – newly dxed, active tx• Surgical, ED, E&M by new Doc

– V54.0, V54.2, V54.8, V54.9 – aftercare• Routine care during healing/recovery, planned• Cast change/removal, removal fixation devices, • Follow-up care visits

• Complications – use appropriate complication codes

Examples Examples

• Fx of tibia due to senile osteoporosis– 733.16, 733.01

• Pathologic fx due to metastatic ca of bone; ovarian ca 5 years ago– 733.14, 198.5, V10.4

Back DisordersBack Disorders

• 724.5 – Back pain, unspecified• 724.2 – Lumbago, Low back pain• 724.5, 307.89 – psychogenic back pain• 722 – Intervertebral disc disorders

– Degeneration vs. displacement (herniation)– Myelopathy with/without –different codes– Herniated disc w/Paresthesia = w/out myelopathy

• 722.7 w/Paralysis = with myelopathy

• Back pain is included in herniated disc codes

Derangement of JointsDerangement of Joints

• Knee Derangement – 717

• Other Derangement – 718– 4th digit for site– 718.3 = recurrent

• Derangement due to current injury– 830-839 – Dislocation of joint

ExamplesExamples

• Chronic lumbosacral sprain– 724.6

• Herniated intervertebral disc, L4-L5– 722.10

• Traumatic arthritis, left ankle, due to old traumatic dislocation– 716.17, 905.6

ICD-9-CM Chapter 17ICD-9-CM Chapter 17

• Chapter organized by– Type of injury, then

anatomical site

• Many inclusion/exclusion notes – need careful attention

• 4th/5th digit – diff info– LOC– # of ribs– Severity of injury

• Fxs – 800-829

• Dislocations –

830-839

• Sprains/Strains –

840-848

Closed vs. OpenClosed vs. Open

• When fx/dislocation NOT specified as open or closed, code closed

• http://www.immediateactionservices.com/femurfractureopen.jpg_jpg.html

Acute Fxs (800-829)Acute Fxs (800-829)

• Apply principles of multiple coding of injuries

• See Handout on Sequencing Injury codes

• Fx of specified site coded individually• 800-829

• Combination codes used when • MR content insufficient in details• Reporting form limits # of codes• Lack of specificity at 4th/5th digit level

DislocationsDislocations

• Dislocation and reduction of dislocation associated w/fx and reduction of fx are included in the fx code

• Open dislocation vs Closed dislocation– Same terms indicate– If open not specified, code closed

Multiple FxsMultiple Fxs• Multiple Fxs of same limb

– IF classified to same 3rd/4th digit category, Code once

• Multiple unilateral/bilateral fx of same bone– IF classified to different 4th digit bone part,

Code individually

• Multiple fx categories 819/828– Bilateral fx of upper limbs, open/closed– Bilateral fx of lower limbs, open/closed

• Sequence most severe first (query Dr)

Acute Fxs vs. AftercareAcute Fxs vs. Aftercare

• Same guidelines as for Pathologic Fxs

• Example - Admitted for removal of internal fixation nail that has protruded into surrounding tissue, causing pain– Main term?– Type of care?– Code?

V codesV codes

• V13.51 - personal hx of pathologic fx

• V13.52 - personal hx of stress fx

• V15.51 - personal hx of traumatic fx

• V54.0 -

• V54.2 -

• V54.8 -

• V54.9 -

E CodesE Codes

• External Causes of Injuries– NOT used w/Pathologic Fxs– Separate Index/Section in ICD-9-CM

ExerciseExercise

• Compound fracture, shaft of radius and ulna, due to tackle in football game

• Aftercare for fracture of L4 vertebra

• Cervical strain due to MVA, 2ndary to loss of control and collision w/tree. Pt was restrained driver.

• Derangement of knee due to fall from ladder while working on house

imueller@email.wcu.edu

ResourcesResources• Arthritis; X-Plain module. Patient Education Institute, Nat’l Library of

Medicine– http://www.nlm.nih.gov/medlineplus/tutorials/arthritis/htm/index.htm

• Arthritis Quiz. Your Orthopaedic Connection; orthopaedic information you can trust. American Academy of Orthopaedic Surgeons

– http://orthoinfo.aaos.org/topic.cfm?topic=A00214

• Brown, Faye. ICD-9-CM Coding Handbook, 2006 with answers. AHA Press.

• Frazier, M. S. & Drzymkowski, J. W. Essentials of Human Diseases and Conditions, 4th ed., Saunders, 2009

• Howard, A. RHIA “Coding for Osteoporosis” For The Record, Vol. 21 No. 3 P. 28 February 2, 2009

ResourcesResources

• ICD-9-CM Official Guidelines for Coding and Reporting, October 1, 2008 – http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide08.pdf

• Mayo Clinic. Bursitis. – http://www.mayoclinic.com/health/bursitis/DS00032

• Moisio M. A. & E. W. Moisio, Understanding Laboratory and Diagnostic Tests, Delmar, 1998 (2nd ed? later)

• Schraffenberger, L. “New ICD-9-CM Diagnosis Codes for FY09” Journal of AHIMA 79, no. 9 (Septemper 2008): 72-75.

• Scott, A. S. & Fong, E. Body Structures and Functions, 11th ed., Delmar, 2009