ms diagnostic coding irene mueller, edd, rhia mha may 21, 2009
TRANSCRIPT
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MS Diagnostic CodingMS Diagnostic Coding
Irene Mueller, EdD, RHIAIrene Mueller, EdD, RHIA
MHAMHAMay 21, 2009May 21, 2009
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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)
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ObjectivesObjectives
• 2nd hour
• ICD -9-CM– Chapter 13 and Chapter 17– V codes, E codes
• Resources
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MS DisordersMS Disorders
• Trauma (major cause)
• Rheumatic
• Inflammatory
• Degenerative
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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
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FracturesFractures
• Caused by stress on bone– Trauma– Severe muscle spasm– Bone disease
• Classified by nature of fx– Mechanism of injury
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Fx EtiologiesFx Etiologies
• Traumatic– MVAs
– Falls
– Assaults
• Pathologic– Spontaneous fxs
– Neoplasms
– TB of bone
– Paget disease• Osteitis
Deformans
– Osteoporosis
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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
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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
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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
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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
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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
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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
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WhiplashWhiplash
• Trauma to cervical vertebrae
• Etiology– Usu. Due to MVA – Head whipped backwards– Stresses neck spine and muscles
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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
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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
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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
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BunionBunion
• Etiology– Associated w/ rheumatoid/osteo arthritis – Flatfoot– High-heels/poorly fitted shoes/Ballet– Familial tendency
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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
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BursitisBursitis
• Etiology– Friction bet. Bursa and MS
(continual/excessive)– Gout, Rheumatoid arthritis– Infection (abrasion/puncture wounds)– Overuse
• Throwing, leaning, kneeling
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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
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Carpal Tunnel SyndromeCarpal Tunnel Syndrome
• Entrapment/Compression of Median Nerve
http://images.medicinenet.com/images/illustrations/carpal_tunnel.jpg
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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
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Pathologic Bone DisordersPathologic Bone Disorders
– Fxs– Osteoarthritis– Rheumatoid arthritis– Gout– Pseudogout– Rickets/Osteomalacia– Osteoporosis– Lyme Disease– Nonunion/Malunion– Neoplasms– Marfan Syndrome
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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Lab TestsLab Tests
• Handout
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Break TimeBreak Time
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ICD-9-CM Chapter 13ICD-9-CM Chapter 13
• Arthritis
• Pathologic Fractures
• Back disorders
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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
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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
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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
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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– ???
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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
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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)
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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
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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
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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
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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
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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
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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
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Closed vs. OpenClosed vs. Open
• When fx/dislocation NOT specified as open or closed, code closed
• http://www.immediateactionservices.com/femurfractureopen.jpg_jpg.html
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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
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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
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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)
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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?
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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 -
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E CodesE Codes
• External Causes of Injuries– NOT used w/Pathologic Fxs– Separate Index/Section in ICD-9-CM
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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
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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
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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