Rehabbing Your Documentation for ICD-10: Musculoskeletal, Sports, Pain and Spine Medicine Sponsored by: American Academy of Physical Medicine and Rehabilitation Annual Assembly 2015 Presented by: Deborah Grider, CDIP, CCS-P, CPC, CPC-I, COC, CPC-P, CPMA, CEMC
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Rehabbing Your Documentation for ICD-10f45ebd178a369304538a-da09e9363888411f910f2103a3cb9db6.r58...Rehabbing Your Documentation for ICD-10: Musculoskeletal, Sports, Pain and Spine
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As the membership organization of health information management professionals, the American Health Information Management Association (AHIMA) fosters the professional development of its members through education, certification, and lifelong learning thereby promoting quality information to benefit the public, the healthcare consumer, providers, and other users of clinical data. American Health Information Management Association (AHIMA) Standards
Standards of Ethical Coding
Coding professionals should:
1. Apply accurate, complete, and consistent coding practices for the production of high-quality healthcare data.
2. Report all healthcare data elements (e.g. diagnosis and procedure codes, present on admission indicator, discharge status) required for external reporting purposes (e.g., reimbursement and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements and applicable official coding conventions, rules, and guidelines.
3. Assign and report only the codes and data that are clearly and consistently supported by health record documentation in accordance with applicable code set and abstraction conventions, rules, and guidelines.
4. Query provider (physician or other qualified healthcare practitioner) for clarification and additional documentation prior to code assignment when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g., present on admission indicator).
5. Refuse to change reported codes or the narratives of codes so that meanings are misrepresented.
6. Refuse to participate in or support coding or documentation practices intended to inappropriately increase payment, qualify for insurance policy coverage, or skew data by means that do not comply with federal and state statutes, regulations, and official rules and guidelines.
7. Facilitate interdisciplinary collaboration in situations supporting proper coding practices.
8. Advance coding knowledge and practice through continuing education.
9. Refuse to participate in or conceal unethical coding or abstraction practices or procedures.
10. Protect the confidentiality of the health record at all times and refuse to access protected health information not required for coding-related activities (examples of coding-related activities include completion of code assignment, other health record data abstraction, coding audits, and educational purposes).
11. Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities.
Revised and approved by the House of Delegates 09/08
Resources, Updated April 2013
AHIMA Code of Ethics
ICD-9-CM Official Guidelines for Coding and Reporting
AHIMA's position statement on Quality Health Data and Information
AHIMA's position statement on Uniformity and Consistency of Healthcare Data
AHIMA Practice Brief titled "Managing an Effective Query Process Source: AHIMA, All Rights Reserved
Deborah Grider works with physician practices and hospital inpatient and outpatient facilities in solo groups, multi-specialty, academic settings and hospital owned practices providing education to physicians and staff on coding and reimbursement issues, and to evaluate reimbursement processes in the medical practice. Deborah has over 32 years of healthcare industry experience in the clinical setting, and as a practice administrator, medical record auditor, clinical documentation improvement practitioner as well as educator. Deborah Grider is a Certified Professional Coder (CPC), a Certified Professional Coder -Instructor (CPC-I), a Certified Professional Coder-Hospital (COC) a Certified Professional Coder-Payer (CPC-P), a Certified Professional Medical Auditor (CPMA), a Certified Evaluation and Management Specialist (CEMC), with the American Academy of Professional Coders, a Certified Coding Specialist-Physician (CCS-P), and Certified Clinical Documentation Improvement Practitioner (CDIP) with the American Health Information Management Association. Deborah teaches and consults with private practices, physician networks, and hospital-based educational programs nationally. She conducts many seminars throughout the year on coding and reimbursement issues She is the former program director of the Medical Coding Program for IU Health. Deborah is considered a national ICD-10 Implementation expert and has provided testimony for the National Committee on Health Care Vital Statistics on ICD-10 implementation challenges for medical practices. She developed the education and training curriculum for ICD-10 Implementation for Physicians and Payors for the American Academy of Professional Coders, and the ICD-10 Implementation Training for the Indiana and Kentucky Hospital Associations. She has also developed webinars on ICD-10 Implementation for Hospital Systems which broadcasts nationally, writes a monthly article “Fast Tracking ICD-10” for ICD-10 monitor and appears regularly as a panelist on “Talk Ten Tuesday”. She served in 2009-2012 on the ICD-10 Stakeholders Committee in Washington, DC as an advisor on the challenges with ICD-10 Implementation. Deborah provides litigation support to attorneys nationally on behalf of their physician and health system clients. Deborah is the author of Principles of ICD-9-CM, Principles of ICD-10-CM, The ICD-10 Workbook, ICD-10 Implementation Guide, Make the Transition Manageable, Coding with Modifiers, and the Medical Record Auditor for the American Medical Association and has been writing for the AMA since 1998. Deborah is past President of the American Academy of Professional Coders National Advisory Board and was a board member for seven years. She is the current president of the Indiana Health Information Management Association. Ms. Grider was awarded her Bachelor’s degree in Business Administration from Indiana University.
Clinical documentation improvement, commonly referred to as CDI, is a process in which to ensure that the practitioners are documenting clearly and concisely and that the documentation supports quality initiatives. When asking physicians why good clinical documentation is necessary, they will most likely say that it is to document the care of the patient and to communicate with other providers. Physicians understand the need to make documentation legible, timely, complete, precise, and clear. They understand that the documentation is the legal health record. They understand the common phrase “If you didn’t document it, it did not happen.” Good Clinical Documentation Will:
Physicians and non-physician practitioners may incorrectly assume that a busy practice equals revenue in the door. What CDI practitioners typically hear is, “we got paid so the coding and documentation must be correct.” That assumption is not always accurate. The insurance carriers use computer systems that initially adjudicate the claims and pay them and typically data mine to audit and monitor claims for inappropriate payment. Insurance carriers can ask for reimbursement refunds from providers who do not code or document accurately for the service provided. For government payers, additional fines and penalties can apply. Every patient encounter begins with documentation. Documentation should accurately depict the patient’s complexity along with the services provided, including, but not limited to:
Office visits
Hospital visits
Diagnostic tests and procedures
Radiology services
Ancillary services
Surgical procedures
Other services
CDI Tip
Documentation begins and ends with the physician in
The patient medical record tells the story of the patient encounter from beginning to end. Clinical documentation improvement (CDI) goes beyond good compliance practices of auditing and monitoring by working toward improving documentation and coding on an ongoing basis.
Most CDI programs are focused on hospital documentation and coding, but in reality, documentation begins and ends with the practitioners (physicians and non-physicians) and should be a medical practice initiative. Clinical Documentation Improvement (CDI) can:
Bridge the gap between the clinicians and coding and billing systems.
Increase and capture appropriate reimbursement for services provided. CDI also refers to the process of improving documentation to better reflect the severity of the patient encounter, as well as to:
Justify the medical necessity for services rendered.
Assist with assigning E/M or procedure codes to support medical necessity.
Help receive accurate reimbursement. While the electronic health record (EHR) has improved the legibility and timeliness of documentation, documentation has become more “cloned” than ever. In an EHR, all of the documentation has started to look the same for every encounter, which can invalidate the encounter during a carrier audit. For many years we have been teaching physicians how to document their evaluation and management (E/M) services, surgical and diagnostic procedures, etc. to get paid for the complexity of their patients, but we have not focused on adding specificity to their diagnoses to support quality of care and medical necessity.
One of the pitfalls of the EHR is that it allows the practitioner to pull information from the patient’s previous visit into the current encounter, which can cause outdated information or misinformation to be entered into the record. If physicians are not familiar with specificity of the diagnosis, make it easy for the physician to provide the correct diagnosis by building logic trees to drill down to specificity. When the practitioner uses a pick-list or a favorites list to select the diagnosis, sometimes the first item on the list is the item chosen, or the list build is not specific and uses more unspecified diagnosis codes, which could be a costly mistake. If using a pick-list it must be compliant and must not lead the physician to choose only a non-specific diagnosis. The medical record must be organized and legible, and every entry must be signed and dated which can be accomplished electronically in the EHR.
Good documentation is the key to supporting services billed on any insurance claim.
Many practitioners are under the assumption that the diagnosis is not that important because they are paid based on the Current Procedural Terminology (CPT
®) and
Healthcare Common Procedure Coding System (HCPCS) codes and the relative value unit (RVU) of the service. But that is not the case. Any claims submitted must:
Include a valid CPT/HCPCS code.
Include the appropriate documentation that supports the code.
Support medical necessity (the overarching criterion for selecting a procedure or service).
It is important to understand that the diagnosis code is just as important. This will be even more important with the implementation of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code set, with its expanded specificity and more detail built into the diagnosis code(s).
Keep in mind that health care reimbursement continues to operate under the numerous regulations and compliance requirements that depend on good documentation. Documentation:
Plays a key role in performance and core measures.
Supports accurate clinical documentation.
Provides a good defense for documentation and coding reviews.
Helps reduce risk and vulnerability from: o Insurance carrier audits o Government payers o Recovery audit contractors (RACs) o Medicaid integrity contractors (MICs) o Zone program integrity contractors (ZPICs) o Office of Inspector General (OIG)
Typically a documentation review (i.e., “audit”) is performed after a claim has been submitted, which leaves the practitioner vulnerable to scrutiny if the documentation does not support the procedure and diagnoses reported on the claim. Clinical documentation improvement (CDI) is a process of reviewing documentation prior to claim submission to avoid inaccurate claim submission. A query is the process in which the physician or non-physician practitioner may clarify coding and/or documentation previously submitted. A query is a question posed to the provider to obtain additional information, clarify documentation, or request an amendment to the medical record in order for the claim to be submitted properly. A query can be a communication and education method to advocate proper documentation practices. The CDI process can help ensure that all procedures and diagnoses are validated in the documentation. If a question arises, the practitioner is sent a query, which can be written or electronic. Many CDI programs utilize the physician query as the method of communication. Queries can be verbal, on paper, or electronic, but the challenge is how to monitor, track, and trend the response to the query. Paper Queries:
• Try to include the query within the progress note or order to ensure that it will be seen by the physician.
• Lends itself better to tracking the data, but getting the documentation into the electronic health record can be more of a challenge.
• An electronic query form that could be easily accessible to the physician, preferably while they are reviewing the clinical record.
• The physician should be able to answer the form electronically and route it back to the CDI specialist/practitioner.
• The completed electronic form should be reviewed to ensure that the documentation is complete.
The presenting problem(s) assists with supporting medical necessity for the patient encounter and assists with accurate reimbursement. It is important to capture all clinical conditions that are managed, treated, worked-up, or monitored with appropriate specificity in the documentation that supports all of the services performed and most important, justifies medical necessary.
How physicians use the electronic health record (EHR) can have a big impact on CDI. EHR technology has clearly improved the legibility and timeliness of clinician documentation. Physicians can use structured templates to input documentation, or they can dictate into a standard progress note format. The problem with the structured templates is that they are not always customized to meet the specific needs of the type of patients treated in the practice. The templates that are normally standard in the EHR should be customized for compliance. Along with all of the benefits of electronic documentation, there are also some significant challenges with electronic documentation. These include:
Cutting and pasting prior documentation into new records, which can obscure new information and increase audit risks.
Many times it is unclear who provided the service.
Symptoms, not diagnoses, are often documented.
Doctors can’t find correct diagnosis from pick-list so they select the first one they see.
Some diagnoses are captured in the problem list and not in the assessment and plan of care.
Some physicians only look in the EHR for information/communication, which can cause a lack of communication in their workflow.
Documentation is not always signed appropriately. Many physicians have embraced electronic documentation since it allows them to quickly complete the daily note. Some physicians like to keep a daily log of events in their notes, so if another practitioner has to cross-cover the patient they only need to read the last note in the chart. This presents a challenge to any coder, clinical documentation improvement practitioner, or auditor who has to review the chart.
Reading the same cut-and-pasted documentation can significantly
decrease productivity and increase the chance for missed opportunities
for coding or documentation clarification. It also promotes “cloning”
The layout of the code set is one area where ICD-10-CM is comparable to ICD-9-CM. It is divided into two main sections: the Alphabetic Index and the Tabular List.
The Alphabetic Index is arranged in alphabetic order by disease, specific illness, injury, eponym, abbreviation or other descriptive diagnostic term. The Index also lists diagnostic terms for other reasons for encounters with health care professionals. The Neoplasm Table provides the proper code based upon histology of the neoplasm and site.
The Neoplasm Table is now located immediately after the main alphabetic index rather than placed alphabetically within it.
The Table of Drugs and Chemicals lists the drug and specific codes that identify the drug and the intent. The Index to External Causes of Injuries is arranged in alphabetic order by main term indicating the event.
Hypertension table has been removed from the Alphabetic Index.
The Tabular List contains codes and descriptors arranged alphanumerically according to body system or condition.
Contains: -Index to Diseases and Injuries
Also includes:
-Neoplasm Table
-Table of Drugs and Chemicals
-Index to External Cause of Injuries
Alphabetic Index List of
alphanumeric codes divided into chapters based on condition and/or body system
Contains categories, subcategories and valid codes
Never select a code directly from the Alphabetic Index. Always confirm final code selection by verifying it in the Tabular List.
Steps to Correct Code Selection
1. Look up the main term in the Alphabetic Index and scan subterm entries making
sure to review additional subterms that may continue into the next column or page. 2. Note all parenthetical terms (nonessential modifiers) that help in code selection, but
do not affect code assignment. 3. Pay attention to instructions in the Index:
“See,” “see also,” and “see category” cross-references
“With”/“without” notes
“Due to” subterms
Other instructions found in note boxes, such as “code by site” 4. Never code from the Alphabetic Index without verifying the accuracy of the code in
the Tabular List. Locate the code in the alphanumerically arranged Tabular List. 5. Read all instructional material:
“Includes” and both types of “excludes” notes
“Use additional code” and “code first underlying disease” instruction
“Code also”
Fourth-, fifth- and sixth-character requirements and seventh-character extension requirement
Age and sex symbols 6. Use the official Draft ICD-10-CM guidelines that govern use of specific codes. 7. Confirm and assign the correct code.
The ICD-10-CM code set is comprehensive and brings with it significant changes not only to the codes themselves, but the overall organization and structure as well.
The ICD-10-CM code set has a broad range of categories for diseases and other health-related conditions. The detail within the codes has been greatly increased by the addition of separate codes for laterality and additional characters that provide even more information about the injury, illness and/or disease.
ICD-9-CM Code Structure
ICD-10-CM Code Structure
• Utilizing all letters except "U." Codes are alphanumeric
• Not all codes contain seven characters; valid codes can be 3, 4, 5, 6, or 7 characters.
Codes are up to seven characters in length
• Do not need to reference back to common fourth and fifth digits like in ICD-9-CM.
2016 ICD-10-CM Guidelines for 7th Character Extensions
While the patient may be seen by a new or different provider over the course of
treatment for an injury, assignment of the 7th character is based on whether the
patient is undergoing active treatment and not whether the provider is seeing
the patient for the first time.
The 7th character “A”, initial encounter is used while the patient is receiving active
treatment for the condition. Examples of active treatment are: surgical treatment,
emergency department encounter, and evaluation and continuing treatment by
the same or a different physician.
7th character “D” subsequent encounter is used for encounters after the patient
has received active treatment of the condition and is receiving routine care for the
condition during the healing or recovery phase. Examples of subsequent care are:
cast change or removal, an x-ray to check healing status of fracture, removal
of external or internal fixation device, medication adjustment, other aftercare and
follow up visits following treatment of the injury.
7th character “S” sequela is used when there is a residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Examples of sequela include: scar formation resulting from a burn, deviated septum due to a nasal fracture, and infertility due to tubal occlusion from old tuberculosis. Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is sequenced second. An exception to the above guidelines are those instances where the code for the sequela is followed by a manifestation code identified in the Tabular List and title, or the sequela code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect or condition.
Note the box indicating to check the 7th character, an “x” is after the check mark to point out the code will require an “x” be placed in the empty character positions
to be able to assign the 7th character extension.
The “X” placeholder also serves another purpose in ICD-10-CM. It is used with certain codes to allow for future code expansion. The “X” placeholder must be used in order for the code to be considered valid.
The Electronic Health Record Many Electronic Health Records use IMO (Intelligent Medical Objects) along with the EHR. With this technology the system is able to build qualifiers or logic to allow for code selection easier than a “pick-list.”
Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial region Spondylosis without myelopathy or radiculopathy, cervicothoracic region Spondylosis without myelopathy or radiculopathy, thoracic region Spondylosis without myelopathy or radiculopathy, thoracolumbar Spondylosis without myelopathy or radiculopathy, lumbar region Spondylosis without myelopathy or radiculopathy, lumbosacral Spondylosis without myelopathy or radiculopathy, sacral an sacrococcygeal Spondylosis without myelopathy or radiculopathy, site unspecified
Other myositis, unspecified site Other myositis, other site Other myositis, multiple sites Other myositis, right shoulder Other myositis, left shoulder Other myositis, unspecified shoulder Other myositis, right upper arm Other myositis, left upper arm Other myositis, unspecified upper arm Other myositis, right forearm Other myositis, left forearm Other myositis, unspecified forearm Other myositis, right hand Other myositis, left hand Other myositis, unspecified hand Other myositis, right thigh Other myositis, left thigh Other myositis, unspecified thigh Other myositis, right lower leg Other myositis, left lower leg Other myositis, unspecified lower leg Other myositis, right ankle and foot Other myositis, left ankle and foot Other myositis, unspecified ankle and foot Myositis, unspecified
Degeneration of intervertebral disc, site unspecified
M51.34 M51.35 M51.36 M51.37
Other intervertebral disc degeneration, thoracic region Other intervertebral disc degeneration, thoracolumbar region Other intervertebral disc degeneration, lumbar region Other intervertebral disc degeneration, lumbosacral region
The risks, benefits, complications, and alternatives to the procedure were discussed in detail and informed written consent was obtained. INDICATIONS: The patient is here to follow up on cervical spondylosis w/o myelopathy (cervicothoracic region), myofascial pain (right shoulder), cervical dystonia, (lumbar region) DDD, and cluster headaches. She is a long-term patient of mine at the Pain Management Clinic and has requested transference because of insurance reasons. Today, she is here for continued management of her many neck-related complaints. Among these are spasms and ongoing pain for which she receives long-acting opioids. She states that she is in fact doing quite well since her cervical fusion. She is requesting that we decrease her medications from 480 mg to 240 mg to 360 mg of morphine per day in the form of Avinza. She also is quite pleased with her other medication regimen which has been greatly simplified over the past year. Some other treatment modalities that have been helpful have included cervical epidural steroid injections. The patient is requesting to have another injection. She states the relief lasted anywhere from four to six months. I agree, this may be helpful because of her intermittent radicular symptoms, particularly in light of her recent surgery. She does complain of hand tingling and numbness, although she is not dropping objects or having difficulties with coordination. In addition, the steroid injections may help expedite her desire to decrease her reliance on medications which have been over-sedating as well as racked with other side effects. DETAILS OF PROCEDURE: Alcohol prep and sterile technique were used. A total of 6 cc of preservative-free 1% lidocaine was used and injected into eight different sites using a 25-gauge, 1-1/2-inch needle at the trapezius muscles bilaterally as well as the levator scapulae, the splenius capitis, and the semispinalis musculature. The procedure was well tolerated.
TREATMENT PLAN:
1. The patient is tentatively scheduled for a cervical epidural steroid injection on March 14, 2005.
2. We will begin a weaning schedule for the patient's Avinza by decreasing in 60 mg intervals. The patient will have a target of 120 mg p.o. b.i.d. and then be reassessed. This is expected to occur after her cervical epidural steroid injection.
Cervical spondylosis w/o myelopathy Unspecified myalgia and myositis Cervical dystonia Degeneration of intervertebral disc, site unspecified Headache
M47.813 M60.811 G24.3 M51.36 G44.009
Spondylosis without myelopathy or radiculopathy, cervicothoracic region Other myositis, right shoulder Spasmodic torticollis Other intervertebral disc degeneration, lumbar region Cluster headache syndrome, unspecified (not intractable)
Documentation for Cervical Spondylosis w/o Myelopathy will need to specify:
Carpal tunnel syndrome, unspecified upper limb Carpal tunnel syndrome, right upper limb Carpal tunnel syndrome, left upper limb
Clinical Example
This is an established patient who has been complaining of left wrist pain for approximately one year. She has been receiving physical therapy for six months and it does not seem to be helping. She is a customer service representative and does repetitive computer work. She has been wearing bilateral wrist supports, which have helped to some extent. Patient has left wrist weakness, unable to touch thumb and little finger together. There is a prominent mass on the palmar aspect of the left wrist.
Assessment and Plan: Patient has carpel tunnel syndrome and will be referred to the orthopedic surgeon for a carpal tunnel surgery. In the meantime, I have placed the patient on pain medication.
Osteophyte, right wrist Osteophyte, left wrist Osteophyte, unspecified wrist Osteophyte, right hand Osteophyte, left hand Osteophyte, unspecified hand Bursitis, unspecified hand Bursitis, right hand Bursitis, left hand Periarthritis, unspecified wrist Periarthritis, right wrist Periarthritis, left wrist Other enthesopathies, not elsewhere classified
Clinical Example The patient presents for an injection for bursitis of the left hand. After the suitable risks of the injection were discussed with the patient, including infection and elevated blood glucose levels, and there were no known allergies to the materials involved with the injection, the patient chose to proceed. The area was cleansed with Hibistat. Using a clean, sterile, no touch technique, a 22 gauge spinal needle entered over the mid-trochanter with the patient in a lateral decubitus position, the needle was advanced to the hand then withdrawn slightly to inject 10 mL of Xylocaine 1%. Following this, the syringe with the Xylocaine was removed while the needle was left intact and 1 mL of Depo-Medrol 80 was injected. This was done without complications. The patient was told that the injection may cause more pain for two to three days afterwards and if this occurred they would best be served by icing the area 15-20 minutes every 6 hours. The patient was advised to protect the left hand by limiting repetitive usage and lifting for a week. Also, they were asked to follow up in two weeks p.r.n.
Radiculopathy, site unspecified Radiculopathy, occipito-atlanto-axial region Radiculopathy, cervical region Radiculopathy, cervicothoracic region Radiculopathy, thoracic region Radiculopathy, thoracolumbar Radiculopathy, lumbar region Radiculopathy, lumbosacral Radiculopathy, sacral and sacrococcygeal region
Low Back Pain
ICD-9 ICD-10
724.2 Lumbago M54.40 M54.41 M54.42 M54.5
Lumbago w/sciatica, unspecified side Lumbago w/sciatica, right side Lumbago w/sciatica, left side Low back pain
Sciatica, unspecified side Sciatica, right side Sciatica, left side Lumbago w/sciatica, unspecified side Lumbago w/sciatica, right side Lumbago w/sciatica, left side
PROCEDURE: Cervical epidural steroid injection without fluoroscopy. ANESTHESIA: Local sedation. VITAL SIGNS: See nurse's notes. COMPLICATIONS: None. DIAGNOSES:
1. Brachial neuritis 2. Low back pain 3. Sciatica
DETAILS OF PROCEDURE: The patient was in the sitting position. The posterior neck and upper back were prepped with Betadine. Lidocaine 1.5% was used for skin wheal made between C7-T1. An 18-gauge Tuohy needle was placed into the epidural space using loss of resistance technique and no cerebrospinal fluid or blood was noted. After negative aspiration, a mixture of 5 cc preservative-free normal saline plus 160 mg Depo-Medrol was injected for the brachial neuritis (cervicothoracic region), low back pain (with sciatica, right side). Neosporin and Band-Aid were applied over the site. The patient discharged to recovery room in stable condition.
Coding
ICD-9 ICD-10
723.4 724.2 724.3
Brachial neuritis or radiculitis NOS Low back pain Sciatica
M54.13 M54.5 M54.31
Radiculopathy, cervicothoracic region Low back pain Sciatica, right side
Note: In the clinical example above, the ICD-10 diagnosis for low back pain with sciatica can also be coded as a combination code (e.g. low back pain with sciatica, right side M54.41).
719.41 Pain in joint, shoulder region M25.511 M25.512 M25.519
Pain in right shoulder Pain in left shoulder Pain in unspecified shoulder
Clinical Example
CHIEF COMPLAINT: Shoulder pain. HISTORY OF PRESENT PROBLEM: Mrs. Jones has had a six-month history of some shoulder pain (right shoulder), and it has not gotten much better. She does not have a history of trauma. It does bother her at night when she sleeps, and she is here now to have it checked out. She has no other focal findings, no numbness or tingling to the fingers and no soreness at the elbow or neck. She is right hand dominant. CLINICAL/PHYSICAL EXAMINATION: Musculoskeletal: Reveals a positive Hawkins sign to the right shoulder with full range of motion and minor tenderness in the rhomboids and to palpation along the ridge of the scapula. No winging of the scapula. Internal/external rotation is intact. No obvious signs of rotator cuff pathology or slack lesion. Elbow and wrist exams are otherwise unremarkable. Contralateral hand exam for comparison reveals no focal findings. CLINICAL IMPRESSION: Right shoulder impingement. EVALUATION/TREATMENT PLAN: At this point, with her consent, explaining the risks and benefits, we talked about cortisone shots. We will try some therapy, pain medicine only as needed and a sleep aide as needed, and then follow-up. If it is not better, she could consider an MRI before coming to visit and we will re-assess. We will consider a cortisone shot at that point. All questions were answered. Therapy for shoulder impingement was outlined.
Informed consent was obtained from the patient. Special mention was made of the possibility of infection and necrosis of the heel pad. The patient was placed in the supine position. The tender area in the medial aspect of the heel was identified by palpation. After proper preparation with antiseptic solution of the skin, a syringe containing 2 mL of 1% lidocaine was attached to 1.5" 27 gauge needle. The needle was carefully advanced through the carefully identified point at a right angle to the skin, directly towards the central and medial aspect of the calcaneus. The needle was advanced very slowly until the needle impinged on the bone, and then was withdrawn slowly. The contents of the syringe were then gently injected. Subsequently, the needle was left in place and a syringe containing 2 mL of 0.25% Marcaine and 1 mL of Depo-Medrol was attached to the needle and injected after aspiration at this site. Subsequently the needle was removed. Pressure was applied at the site of insertion and once it was made sure there was no bleeding taking place, a small bandage was applied.
355.6 Lesion of plantar nerve G57.60 G57.61 G57.62
Lesion of plantar nerve, unspecified lower limb Lesion of plantar nerve, right lower limb Lesion of plantar nerve, left lower limb
Clinical Example
PROCEDURE: Morton’s Neuroma Injection DIAGNOSES:
1. Lesion of plantar nerve
Informed consent was obtained from the patient. The patient was placed in the supine position. The Morton's neuroma was localized by careful palpation and was found to be between the plantar nerve (right lower limb). The area was cleaned and subsequently a 25 gauge needle was inserted half way between the MTP heads and advanced in a vertical position down through the transverse metatarsal ligament. 0.5 mL of Depo-Medrol and 0.5 mL of 0.25% Marcaine were injected at this site after aspiration. Post-procedure no complications were noted. Pressure was applied for a period of two minutes and a small dressing applied.
Coding
ICD-9 ICD-10
355.6 Lesion of plantar nerve G57.61 Lesion of plantar nerve, right lower limb
Documentation for Lesion of Plantar Nerve will need to specify:
Case 8 - Pain in Joint, Lower Leg, Occipital Neuralgia and Neck Pain
Pain in Joint, Lower Leg
ICD-9 ICD-10
719.46 Pain in joint in lower leg M25.561 M25.562 M25.569
Pain in right knee Pain in left knee Pain in unspecified knee
Occipital Neuralgia
ICD-9 ICD-10
723.8 Other syndromes affecting cervical region
M53.81 M53.82 M53.83 M54.81
Other specified dorsopathies, occipito-atlanto-axial region Other specified dorsopathies, cervical region Other specified dorsopathies, cervicothoracic region Occipital neuralgia
CHIEF COMPLAINT: Right lower extremity pain, back pain, and neck pain. HISTORY OF PRESENT ILLNESS: Ms. XYZ is a 76-year-old resident of ASDF. She is seen at the request of Dr. ABC. She carries a diagnosis of pain in lower leg, occipital neuralgia, and neck pain. She underwent an L3-4 decompression in December of 2013 by Dr. Johnson for back and bilateral lower leg pain. Shortly after surgery, she began having pain in the right knee and is seen today with an outside lumbar MRI only. I have a report of a lumbar CT myelogram as well, but no films. She has occipital neuralgia and neck pain. She has a foraminal disc protrusion on the right, as well as a severely degenerated disc at L3-4. The patient complains essentially of pain along the dorsopathies, cervical region which is burning, shooting, aching and constant in nature. It is worse with standing and walking. She can walk about a block before her symptoms become debilitating. She is more comfortable in recumbency. She denies bowel or bladder dysfunction, saddle area hypoesthesia, numbness, tingling, weakness or Valsalva related exacerbation. She rates her pain as 9/10 in average and her daily level of intensity and 5/10 for her least level of pain. Alleviating factors include sitting, recumbency, sleeping, and massage. She treats her pain with Tylenol currently. REVIEW OF SYSTEMS: A complete review of systems was surveyed and is otherwise negative. The patient denies any other constitutional symptom. PHYSICAL EXAMINATION: Temp 97.7, pulse 78, BP 143/80. The patient walks with a slight forward stooped gait. There is no spasticity or ataxia. She has mild antalgia after a few steps to the right lower extremity. She has limited lumbar flexion, lumbar extension and right ipsilateral bending with provocable right leg pain. Lungs are clear to auscultation. Heart has regular rate and rhythm with normal S1, S2. No murmurs, rubs, or gallops. The abdomen is obese, nontender, nondistended without palpable organomegaly or pulsatile masses. The skin is warm and dry to touch. There is no cyanosis, clubbing, or edema. Degenerative changes are noted in the joints of the hands, knees and ankles. IMPRESSION: 1. Lower leg pain 2. Occipital neuralgia 3. Neck pain PLAN: The risks and benefits of right L4 selective nerve root block were discussed in detail with the patient and they include failure of pain relief, need for further procedures, infection, bleeding, damage to the spinal nerves or abdominal viscera, and postdural puncture headaches. She wished to proceed.
PROCEDURE: Sacroiliac Joint Injection Informed consent was obtained from the patient. The patient was placed in the prone position. After preparation, local anesthetic administration, and image intensifier control, a 25 gauge spinal needle was directed into the inferior aspect of the sacroiliac joint using a posterior approach. A small amount of contrast material was administered to outline the recesses of the joints. Verification of the initial needle position with contrast administration, 1 mL of solution was administered at this site after aspiration, consisting of 0.5 mL of 0.25% Marcaine and 0.5 mL of Celestone. Post-procedure, the needles were withdrawn and dressing was applied. Post-procedure no complications were noted.
Coding
ICD-9 ICD-10
720.2 Sacroiliitis, not elsewhere classified
M46.1 Sacroiliitis, not elsewhere classified
ICD-10 CM does not require any additional documentation for Sacroiliac.
Other synovitis and tenosynovitis, right forearm Other synovitis and tenosynovitis, left forearm Other synovitis and tenosynovitis, unspecified forearm Other synovitis and tenosynovitis, right hand Other synovitis and tenosynovitis, left hand Other synovitis and tenosynovitis, unspecified hand
POSTOPERATIVE DIAGNOSES 1. Tenosynovitis of the left third and fourth fingers at the A1 and A2 pulley level. 2. Left carpal tunnel syndrome.
PROCEDURE: Left carpal tunnel release with flexor tenosynovectomy; cortisone injection of trigger fingers, left third and fourth fingers ANESTHESIA: Local plus IV sedation (MAC). PROCEDURE DETAIL: Patient brought to the operating room. After induction of IV, sedation of the left hand was anesthetized suitable for carpal tunnel release; 10 cc of a mixture of 1% Xylocaine and 0.5% Marcaine was injected in the distal forearm and proximal palm suitable for carpal tunnel surgery. Routine prep and drape was employed. Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet and tourniquet inflated to 250 mmHg pressure. Hand was positioned palm up in the lead hand-holder. A short curvilinear incision about the base of the thenar eminence was made. Skin was sharply incised. Sharp dissection was carried down to the transverse carpal ligament and this was carefully incised longitudinally along its ulnar margin. Care was taken to divide the entire length of the transverse retinaculum including its distal insertion into deep palmar fascia in the midpalm. Proximally the antebrachial fascia was released for a distance of 2-3 cm proximal to the wrist crease to insure complete decompression of the median nerve. Retinacular flap was retracted radially to expose the contents of the carpal canal. Median nerve was identified, seen to be locally compressed with moderate erythema and mild narrowing. Locally adherent tenosynovitis right forearm was present and this was carefully dissected free. Additional tenosynovium was dissected from the flexor tendons, individually stripping and peeling each tendon in sequential order so as to debulk the contents of the carpal canal. Epineurotomy and partial epineurectomy were carried out on the nerve in the area of mild constriction to relieve local external scarring of the epineurium. When this was complete retinacular flap was laid loosely in place over the contents of the carpal canal and skin only was closed with interrupted 5-0 nylon horizontal mattress sutures. A syringe with 3 cc of Kenalog-10 and 3 cc of 1% Xylocaine using a 25 gauge short needle was then selected; 1 cc of this mixture was injected into the third finger A1 and A2 pulley tendon sheaths using standard trigger finger injection technique; 1 cc was injected into the fourth finger A1/A2 pulley tendon sheath using standard tendon sheath injection technique. Routine postoperative hand dressing with well-padded, well-molded volar plaster splint and lightly compressive Ace wrap was applied. Tourniquet was deflated. Good vascular color and capillary refill were seen to return to the tips of all digits. Patient discharged to the ambulatory recovery area and from there discharged home. Discharge medication is Darvocet-N 100, 30 tablets, one to two PO q.4h. p.r.n. Patient asked to begin gentle active flexion, extension and passive nerve glide exercises beginning 24-48 hours after surgery. She was asked to keep the dressings clean, dry, and intact and follow-up in my office.
Intervertebral disc disorders with radiculopathy, thoracic region Intervertebral disc disorders with radiculopathy, thoracolumbar region Intervertebral disc disorders with radiculopathy, lumbar region Intervertebral disc disorders with radiculopathy, lumbosacral region Radiculopathy, thoracic region Radiculopathy, thoracolumbar region Radiculopathy, lumbar region Radiculopathy, lumbosacral region
Back Pain
ICD-9 ICD-10
724.5
Unspecified backache M54.89 M54.9 M54.5
Other dorsalgia Dorsalgia, unspecified Low back pain
PROCEDURE: Placement of intrathecal catheter for trial for permanent Medtronic SynchroMed pump. POST OPERATIVE DIAGNOSIS: Lumbar radiculopathy and back pain The patient is a 65 year old woman with lumbar radiculopathy (lumbar region) and low back pain with a history of three prior lumbar spine surgeries. She is well known to me from multiple prior therapeutic attempts with mixed success. She has failed oral narcotic therapy because the drugs make her dizzy, disoriented and itchy. Physical exam was performed for the patient’s admission to the hospital. Detailed consent was obtained, and the patient agreed to proceed. Patient was placed in the prone position on the C-arm fluoroscopy table. Cerebrospinal fluid emerged from the tip of the catheter. 1.2 mg of preservative-free morphine was injected. The catheter was secured with benzoin and a Biopatch dressing. The patient will be followed for the next two to three days in the hospital on a continuous intrathecal morphine infusion.
Coding
ICD-9 ICD-10
724.4 724.5
Thoracic or lumbosacral neuritis or radiculitis, unspecified Unspecified, backache
M54.16 M54.5
Radiculopathy, lumbar region Low back pain
Documentation for Lumbar Radiculopathy will need to specify:
DIAGNOSIS: Inflammatory Spondylitis and Left Sciatica. ANESTHESIA: Intravenous sedation NAME OF OPERATION: 1. Left L5-S1 transforaminal epidural steroid block with fluoroscopy. 2. Left L4-5 transforaminal epidural steroid block with fluoroscopy. 3. Monitored intravenous Versed sedation. PROCEDURE: Patient is here in hopes of achieving relief for inflammatory spondylopathy, lumbar region and sciatica of the left side. The patient was taken
to the block room. He was placed prone on the fluoroscopy table. He was monitored appropriately. He was administered Versed 2 mg IV. His O2 saturation remained greater than 90%. His back was prepped and draped. The C-arm was brought in. The endplates at L5-S1 were squared off. The C-arm was rotated to the left. The L5 pedicle, the superior articular process of the L5-S1 facet, and the "neck of the scotty dog" were all visualized. After adequate local anesthesia, a 22-gauge, 3-1/2-inch spinal needle was inserted using down-the-barrel-of-the-needle technique. The needle was advanced into the posterior aspect of the foramen and then advanced anteriorly toward the 6 o'clock position on the pedicle. No paresthesias were noted. One-half cc of contrast was injected and spread medially around the pedicle and into the epidural space, and the L5 nerve root was visualized. Depo-Medrol 80 mg plus 1 cc of 4% preservative-free lidocaine was injected. The needle was flushed and removed.
Coding
ICD-9 ICD-10
720.9 724.3
Unspecified inflammatory spondylopathy Sciatica
M54.30 M54.32
Unspecified inflammatory spondylopathy, lumbar region Sciatica, left side
Spinal stenosis, site unspecified Spinal stenosis, occipito-atlanto-axial region Spinal stenosis, cervical region Spinal stenosis, cervicothoracic Spinal stenosis, thoracic region Spinal stenosis, thoracolumbar Spinal stenosis, lumbar Spinal stenosis, lumbosacral region Spinal stenosis, sacral and sacrococcygeal region
Clinical Example
DIAGNOSIS: Severe spinal stenosis ANESTHESIA: General PROCEDURE: 1. Implantation of intraspinal catheter 2. Implantation of intraspinal pump INDICATION FOR PROCEDURE: The patient is here today for implantation of an intraspinal morphine pump. The patient failed previous oral narcotics for issues of side effects and complications for severe spinal stenosis of the thoracolumbar region. DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was taken to the operating room. The patient was placed in a lateral decubitus position. The area over the back, flank and abdomen was prepped with Betadine and draped in a standard sterile fashion. A two-inch incision was made over the L3 to L5 vertebral bodies, dissected down to the posterior spinous ligament. A 15-gauge intraspinal needle was introduced into the arachnoid space with return of clear fluid. Medtronic catheter, #8703, was advanced through the needle under fluoroscopic guidance of approximately 2-1/2 to 3 vertebral segments. A small pocket was then made just to the side of the midline incision subcutaneously. On the abdomen, an incision was then made at about the level of the umbilicus but more lateral. The incision was extended to about 3-1/2 to 4 inches to accommodate the pump. The pump was thus secured into the pocket. The wound was then closed with #0 Vicryl subcutaneously and 5-0 nylon on the surface. The patient was taken to recovery in satisfactory condition.
DIAGNOSIS: Congenital spondylolisthesis PROCEDURE PERFORMED: Fluoroscopic interlaminar L4-L5 lumbar epidural steroid injection DESCRIPTION OF PROCEDURE: Detailed consent was obtained for fluoroscopic interlaminar epidural steroid injection. The patient has agreed to proceed with the injection for congenital spondylolisthesis. The patient was placed in the prone position on the C-arm fluoroscopy table. The lumbar area was prepped and draped in the usual sterile fashion using Betadine. A 25 gauge skin wheal using 1% Xylocaine was placed in the skin overlying the right L4-L5 epidural space. A mixture of Xylocaine 1% 4cc and Depo-Medrol 80mg was injected without difficulty. The patient tolerated the procedure well and was discharged in approximately an hour with full recovery of sensory and motor function.
Upper abdominal pain, unspecified Right upper quadrant pain Left upper quadrant pain Epigastric pain Lower abdominal pain, unspecified Right lower quadrant pain Left lower quadrant pain Periumbilical
Clinical Example
DIAGNOSIS: Chronic abdominal pain PROCEDURE PERFORMED: Celiac Plexus Block ANESTHESIA: Local/IV sedation COMPLICATIONS: None DESCRIPTION OF PROCEDURE: The procedure is being performed in hopes of relief for chronic abdominal pain in upper abdomen and right lower quadrant. The patient was placed in the prone position. Back prepped and draped in sterile fashion. Then 1.5% of Lidocaine for skin wheal was made approximately 10 cm lateral to the L1-L2 vertebral junction. A 20 gauge, 15 cm needle was then placed in a cephalad medial 45degree direction; the tip of the needle was just inside the L1 vertebral body. On lateral view, this was noted to be approximately 1.5-2.5 cm anterior to the vertebral body. At this time, 3 cc of Omnipaque dye was injected to the opposite side where the same sequence was performed. Following this, a mixture of 18 cc of 0.5% Marcaine was injected on each side. Neosporin and Band-Aids were applied over the puncture sites. The patient was taken to the outpatient recovery where blood pressure was monitored and fluids given as needed. The patient was discharged to operating room recovery in stable condition.
Pain in right arm Pain in left arm Pain in arm, unspecified Pain in right leg Pain in left leg Pain in leg, unspecified Pain in unspecified limb Pain in right upper arm Pain in left upper arm Pain in unspecified upper arm Pain in right forearm Pain in left forearm Pain in unspecified forearm Pain in right hand Pain in left hand Pain in unspecified hand Pain in right finger(s) Pain in left finger(s) Pain in unspecified finger(s) Pain in right thigh Pain in left thigh Pain in unspecified thigh Pain in right lower leg Pain in left lower leg Pain in unspecified lower leg Pain in right foot Pain in left foot Pain in unspecified foot Pain in right toe(s) Pain in left toe(s) Pain in unspecified toe(s)
A 90-year old woman comes in complaining of chronic pain in her left hip. She is
unable to bear weight on her left leg. She fell from the left side of her bed while
resting. This happened 3 months ago and she still is experiencing severe pain.
This happened while she was at the nursing home. This is the second time this
has happened. A hip x-ray was taken and no fracture was detected.
The patient was released back to the nursing home.
Coding
ICD-9 ICD-10
338.21 959.6 E884.4
Chronic pain due to trauma Injury, other and unspecified hip and thigh Accidental fall from bed
G89.21 S79.912D Y93.84 Y92.122 W06.XXXD
Chronic pain due to trauma Unspecified injury of left hip, subsequent encounter Activity, sleeping Bedroom in nursing home as the place of occurrence Fall from bed, subsequent encounter
Documentation required for Chronic Pain Due to Trauma will need to include:
Type o Chronic o Post-thoracotomy o Post-procedure o Other
Case 18 - Lumbar Intervertebral Disc without Myelopathy
Lumbar Intervertebral Disc without Myelopathy
ICD-9 ICD-10
722.10 Lumbar intervertebral disc without myelopathy
M51.24 M51.25 M51.26 M51.27
Other intervertebral disc displacement, thoracic region Other intervertebral disc displacement, thoracolumbar region Other intervertebral disc displacement, lumbar region Other intervertebral disc displacement, lumbosacral region
Clinical Example
The patient is a 33-year-old Caucasian female who had 2 prior lumbar laminectomy
surgeries at L5-S1 (the bottom level of the spine). Her leg pain improved after these two
spinal operations, but her low back pain increased due to progressive collapse of the L5-
S1 intervertebral disc. She tried three years of conservative therapy all of which failed to
relieve her ongoing low back pain. A subsequent pregnancy increased the stress on her
lumbar spine and made the low back pain significantly worse.
The patient presents today to discuss options going forward. After spending
approximately 45 minutes going over several options, the patient has decided to
proceed with a disc replacement surgery.
Impression/Plan: Intervertebral disc displacement, lumbar region
Case 19-Displacement of Cervical Intervertebral Disc without Myelopathy
Displacement of Cervical Intervertebral Disc without Myelopathy
ICD-9 ICD-10
722.0
Displacement of cervical intervertebral disc without myelopathy
M50.20 M50.21 M50.22 M50.23
Other cervical disc displacement, unspecified cervical region Other cervical disc displacement, high cervical region Other cervical disc displacement, mid cervical region Other cervical disc displacement, cervicothoracic region
Clinical Example
The patient arrives to the office today to follow-up on treatment of his cervical C5-C6
(mid-cervical region) disc displacement. Jon has had spondylosis (degenerative
osteoarthritis) of the cervical region for a number of years and just recently
diagnosed with C5-C6 cervical disc displacement. Last month we started Jon on anti-
inflammatory and today I would like to check on his progress.
847.2 Lumbar sprain and strain S33.5XXA S33.5XXD S33.5XXS
Sprain of ligaments of lumbar spine, initial encounter Sprain of ligaments of lumbar spine, subsequent encounter Sprain of ligaments of lumbar spine, sequela
In ICD-10, the appropriate 7th character is to be added to each code from category S33.
A
D
S
Initial encounter
Subsequent
encounter
Sequela
Clinical Example
Mrs. Smith is seen today for complaint of a lumbar sprain, initial encounter which is
causing intense pain. Her pain is worse with sitting, standing, and is essentially worse
in the supine position. She states her right shoulder pain is constant on the anterior
lateral aspect and radiates down into the bicep area. She denies associated bowel or
bladder dysfunction, saddle area hypoesthesia, or falls. She has treated her back
symptoms with heat and ice, but would like physical therapy as well.
She is intolerant to any type of anti-inflammatory medications and has a number of
allergies to multiple medications. Her pain is described as constant, aching, and on a
scale of 1-10, pain is a 7.
Images for cervical and lumbar spine will be ordered. F/U in 2 weeks for results and possible options pending results.
Spinal stenosis, site unspecified Spinal stenosis, occipito-atlanto-axial region Spinal stenosis, cervical region Spinal stenosis, cervicothoracic region Spinal stenosis, thoracic region Spinal stenosis, thoracolumbar region Spinal stenosis, lumbar region Spinal stenosis, lumbosacral region Spinal stenosis, sacral and sacrococcygeal region
Clinical Example
Patient presents for follow-up on spinal stenosis. She has been doing well and has no
additional complaints.
Impression: Lumbar spinal stenosis.
Patient to return to clinic in 3 months or sooner as needed and to continue current regimen.
Radiculopathy, site unspecified Radiculopathy, occipito-atlanto-axial region Radiculopathy, cervical region Radiculopathy, cervicothoracic region Radiculopathy, thoracic region Radiculopathy, thoracolumbar Radiculopathy, lumbar region Radiculopathy, lumbosacral Radiculopathy, sacral and sacrococcygeal region
Clinical Example
Patient is seen with sudden onset of severe pain in the muscles of the cervical
region and frequently the arm and neck. Numbness and muscle weakness also
mentioned. No shortness of breath.
On exam the arm muscles had decreased reflexes and the shoulder had decreased
sensation.
IMPRESSION: Radiculopathy, cervical region.
Plan: Nerve conduction studies ordered and x-ray of shoulder. Patient was prescribed Percocet. Follow-up in 1 week.
Spinal stenosis, site unspecified Spinal stenosis, occipito-atlanto-axial region Spinal stenosis, cervical region Spinal stenosis, cervicothoracic region Spinal stenosis, thoracic region Spinal stenosis, thoracolumbar region Spinal stenosis, lumbar region Spinal stenosis, lumbosacral region Spinal stenosis, sacral and sacrococcygeal region
Clinical Example
Patient presents for follow-up on spinal stenosis. She has been doing well and has no
additional complaints.
Impression: Lumbar spinal stenosis.
Patient to return to clinic in 3 months or sooner as needed and to continue current regimen.
Cervical disc disorder with myelopathy, unspecified cervical region Cervical disc disorder with myelopathy, high cervical region Cervical disc disorder with myelopathy, mid cervical region Cervical disc disorder with myelopathy, cervicothoracic region Cervical disc disorder with radiculopathy, unspecified cervical region Cervical disc disorder with radiculopathy, high cervical region Cervical disc disorder with radiculopathy, mid-cervical region Cervical disc disorder with radiculopathy, cervicothoracic region Other cervical disc displacement, unspecified cervical region Other cervical disc displacement, high cervical region Other cervical disc displacement, mid cervical region Other cervical disc displacement, cervicothoracic region
Cervical disc displacement without myelopathy Degeneration of cervical intervertebral disc
M50.30 M50.31 M50.32
Other cervical disc degeneration, unspecified cervical region Other cervical disc degeneration, high cervical region Other cervical disc degeneration, mid cervical region
Clinical Example
Chief Complaint: “My neck hurts and I have a tingling pain sensation going down my right arm.” Patient is a 68 year-old male with history of neck pain that has been worsening over the last two years. Recently, he has experienced some numbness and a painful tingling sensation in his right arm going down to his thumb. No other symptoms or pertinent medical history. Review of systems is negative except for the neck pain and sensations in his right arm described above. No history of acute injury to neck or arm. Physical exam is normal except for neurological exam of the right upper extremity, which reveals slight decrease to sensation in the thumb and forefinger region of the hand in the C6 nerve root distribution. No evidence of weakness in the muscles of the arm or hand. MRI scan of the neck shows degenerative changes of the C5-6 disc with lateral protrusion of disc material. No other abnormalities noted. Assessment and Plan Cervical transforaminal injection at C5-6
Acute embolism and thrombosis of unspecified deep veins of right lower extremity Acute embolism and thrombosis of unspecified deep veins of left lower extremity Acute embolism and thrombosis of unspecified deep veins of bilateral lower extremity Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity Acute embolism and thrombosis of right femoral vein Acute embolism and thrombosis of left femoral vein Acute embolism and thrombosis of bilateral femoral vein Acute embolism and thrombosis of unspecified femoral vein Acute embolism and thrombosis of right iliac vein Acute embolism and thrombosis of left iliac vein Acute embolism and thrombosis of bilateral iliac vein Acute embolism and thrombosis of unspecified iliac vein Acute embolism and thrombosis of right popliteal vein Acute embolism and thrombosis of left popliteal vein Acute embolism and thrombosis of bilateral popliteal vein Acute embolism and thrombosis of unspecified popliteal vein Acute embolism and thrombosis of right tibial vein Acute embolism and thrombosis of left tibial vein Acute embolism and thrombosis of bilateral tibial vein Acute embolism and thrombosis of unspecified tibial vein
Acute embolism and thrombosis of other specified deep vein of right lower extremity Acute embolism and thrombosis of other specified deep vein of left lower extremity Acute embolism and thrombosis of other specified deep vein of bilateral lower extremity Acute embolism and thrombosis of other specified deep vein of unspecified lower extremity Acute embolism and thrombosis of unspecified deep veins of right proximal lower extremity Acute embolism and thrombosis of unspecified deep veins of left proximal lower extremity Acute embolism and thrombosis of unspecified deep veins of bilateral proximal lower extremity Acute embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity Acute embolism and thrombosis of unspecified deep veins of right distal lower extremity Acute embolism and thrombosis of unspecified deep veins of left distal lower extremity Acute embolism and thrombosis of unspecified deep veins of bilateral distal lower extremity Acute embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity Chronic embolism and thrombosis of unspecified deep veins of right lower extremity Chronic embolism and thrombosis of unspecified deep veins of left lower extremity Chronic embolism and thrombosis of unspecified deep veins of bilateral lower extremity
Chronic embolism and thrombosis of unspecified deep veins of unspecified lower extremity Chronic embolism and thrombosis of right femoral vein Chronic embolism and thrombosis of left femoral vein Chronic embolism and thrombosis of bilateral femoral vein Chronic embolism and thrombosis of unspecified femoral vein Chronic embolism and thrombosis of right iliac vein Chronic embolism and thrombosis of left iliac vein Chronic embolism and thrombosis of bilateral iliac vein Chronic embolism and thrombosis of unspecified iliac vein Chronic embolism and thrombosis of right popliteal vein Chronic embolism and thrombosis of left popliteal vein Chronic embolism and thrombosis of bilateral popliteal vein Chronic embolism and thrombosis of unspecified popliteal vein Chronic embolism and thrombosis of right tibial vein Chronic embolism and thrombosis of left tibial vein Chronic embolism and thrombosis of bilateral tibial vein Chronic embolism and thrombosis of unspecified tibial vein Chronic embolism and thrombosis of other specified deep vein of right lower extremity Chronic embolism and thrombosis of other specified deep vein of left lower extremity Chronic embolism and thrombosis of other specified deep vein of bilateral lower extremity
Chronic embolism and thrombosis of other specified deep vein of unspecified lower extremity Chronic embolism and thrombosis of unspecified deep veins of right proximal lower extremity Chronic embolism and thrombosis of unspecified deep veins of left proximal lower extremity Chronic embolism and thrombosis of unspecified deep veins of bilateral proximal lower extremity Chronic embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity Chronic embolism and thrombosis of unspecified deep veins of right distal lower extremity Chronic embolism and thrombosis of unspecified deep veins of left distal lower extremity Chronic embolism and thrombosis of unspecified deep veins of bilateral distal lower extremity Chronic embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity
CHIEF COMPLAINT: Increased weakness and fever. HISTORY OF PRESENT ILLNESS: This is a 59-year-old white male with history of large hemispheric stroke two months ago. Since that time, the patient has been aphasic and difficult to ambulate with right sided weakness. Two days prior to presentation to the hospital, he started having some increased problems with coordination, some increased problems with weakness and therefore presented to the emergency department after the patient developed fever at home. MEDICATIONS AT HOME: Zoloft 100 mg daily. Senokot as needed for constipation. Aspirin 325 mg daily. Colace 100 mg daily as needed for constipation. PAST MEDICAL HISTORY: Significant for left sided cerebrovascular accident, left hemisphere, 2002. At that time, the patient was found to have complete left internal carotid occlusion, felt inoperable at that time. The patient also had a left fem-pop procedure back in 2013. The patient quit smoking and quit his chronic alcohol use when he had the stroke. The patient did not know his parents. The patient is retired. The patient lives with his son. The patient also has two other sons. REVIEW OF SYSTEMS: Difficult to get with the patient unable to talk. It is apparent based on my observation he has some left leg pain. PHYSICAL EXAMINATION: GENERAL/VITAL SIGNS: The patient was febrile with temperature of 102. The rest of the vital signs were stable. This is a well-developed, well-nourished white male who looks older than his stated age, in no acute distress. HEENT: The patient has no bruits, no thyromegaly, no lymphadenopathy. CHEST: The patient does have crackles at the bases, otherwise sounds clear. CARDIAC: Regular rate and rhythm without any murmurs heard. ABDOMEN: Benign, soft, positive bowel sounds, nontender, nondistended, no hepatosplenomegaly. EXTREMITIES: The patient has palpable pedal pulses but decreased, 1+ edema, greater on the right than the left, with chronic redness. The patient has developed stiffness of his right upper extremity. Keeping a closed fist is difficult. The patient does have some weakness here also.
IMPRESSION AND PLAN: Admit as inpatient. 1. Pneumonia. I am concerned about aspiration with right upper lobe and left lower
lobe affected. The patient is on Zosyn, which is the appropriate antibiotic. We will
ask Speech also to do a swallowing study on this patient.
2. Hyperglycemia. This was never an issue before but patient was hyperglycemic on admission. We will check his blood sugars throughout the hospital course.
3. With his previous stroke, there is concern that the patient is using his right side even worse than before. We will obtain MRI of the patient to see if new thrombotic event has happened.
4. Deep venous thrombosis prophylaxis. We will use Lovenox.
Coding in ICD-10
ICD-9 ICD-10
486 Pneumonia J18.1
Lobar pneumonia, unspecified organism
790.29 Other abnormal glucose R73.09 Other abnormal glucose
453.40 Deep vein thrombosis I82.5Z9 Chronic embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity (Query)