Coding Gout, Obesity, and Routine Exams

Presented by Beth Sassano CPC, CPC-I, CCS-P, CPMA

A condition marked by increased levels of uric acid in the blood, joints, and tissue. The buildup of uric acid in the joints and tissues causes arthritis and inflammation.

Gout is a common, painful form of arthritis. It causes swollen, red, hot and stiff joints. It happens if your body produces extra acid or does not eliminate enough, or if you eat too many foods with purines, such as liver and dried beans.

Pseudogout has similar symptoms and is sometimes confused with gout. However, it is caused by calcium phosphate, not uric acid. Often, gout first attacks your big toe. It can also attack ankles, heels, knees, wrists, fingers and elbows. You are more likely to get gout if you

◦ are a man◦ have family member with gout◦ drink alcohol

Clinical Information

At first, gout attacks usually get better in days but eventually, attacks can last longer and happen more often.

Untreated gout can cause permanent joint and kidney damage. You can treat gout with medicines. (nih: national institute of arthritis and musculoskeletal and skin diseases)

Hereditary metabolic disorder characterized by recurrent acute arthritis, hyperuricemia and deposition of sodium urate in and around the joints, sometimes with formation of uric acid calculi.

Gout

Check if the pain is Joint Pain, is Arthritic or Gout?

Watch for Tophi:Some patients who have a longstanding gout diagnosis may develop tophi. “A tophus (the singular form of tophi) is a mass of uric acid crystals that often appear around joints. Less common locations for tophi can include the patient’s cartilage, bone, synovium, skin, kidneys, or other organs. The deposits often signify chronic gout since they usually take about 10 years to develop after the onset of gout.”

“Tophi are more common in men than women, but the incidence in women increases after they reach menopause,” says Ruby O’Brochta-Woodward, BSN, CPC, CCS-P, COSC, ACS-OR, a compliance and research specialist with Twin Cities Orthopedics, P.A.

Questions for coders to answer from the Documentation:

Coding gout in ICD-10-CM will require documentation to identify “with” or “without tophus”.

Not only will the requirement of coding “with” or “without tophus” allow more code choices, so will the expansion of codes sets in Chapter 13.

The presence of tophi would need to be supported by documentation, and the causative factor and location of gout would determine code selection.

Documentation

Applicable To Acute gout Gout attack Gout flare Gout NOS

Type 1 Excludes chronic gout M1A.-

Categories in Gout M10-

In ICD-10, chronic gout is classified to a series of codes beginning with M1A. A fourth character further classifies the gout as follows:

◦ M1A.0 Idiopathic◦ M1A.1 Lead-induced◦ M1A.2 Drug-induced◦ M1A.3 Chronic gout due to renal impairment◦ M1A.4 Other secondary chronic gout◦ M1A.9 Chronic gout, unspecified

Fifth and sixth characters can further specify location of the chronic gout. For example, M1A.011 indicates “Idiopathic chronic gout, right shoulder.”

To indicate with tophus (or tophi), simply append the seventh character of “1.”

A seventh character of “0” indicates “without tophus (tophi).”

These seventh characters may be added to any code from category M1A. Thus, unspecified chronic gout with tophus (tophi) would be coded as M1A.9xx1.

M1A.-

Gout is not a diagnosis that will easily crosswalk from ICD-9 to ICD-10-CM, so documentation is key for correct code assignment.For example:

◦ Code 274.00 (Gouty arthropathy, unspecified) is listed as M10.00 (Idiopathic gout, unspecified site) in ICD-10-CM. This is only for an unspecified site.

The provider must document the site that is affected by gout.

For example:◦ M10.01 (idiopathic gout, shoulder) will need to be coded with one of the

following codes: ◦ M10.011 (idiopathic gout, right shoulder), ◦ M10.012 (idiopathic gout, left shoulder), or ◦ M10.019 (idiopathic gout, unspecified shoulder).

Documentation

Use Additional code to identify:

Autonomic neuropathy in diseases classified elsewhere (G99.0)

Calculus of urinary tract in diseases classified elsewhere (N22)

Cardiomyopathy in diseases classified elsewhere (I43) Disorders of external ear in diseases classified

elsewhere (H61.1-, H62.8-) Disorders of iris and ciliary body in diseases classified

elsewhere (H22) Glomerular disorders in diseases classified elsewhere (

N08)

Coders: From the Documentation:

M10 Gout M10.0 Idiopathic gout M10.00 …… unspecified site M10.01 Idiopathic gout, shoulder M10.011 Idiopathic gout, right shoulder M10.012 Idiopathic gout, left shoulder M10.019 Idiopathic gout, unspecified

shoulder M10.02 Idiopathic gout, elbow M10.021 Idiopathic gout, right elbow M10.022 Idiopathic gout, left elbow M10.029 Idiopathic gout, unspecified

elbow M10.03 Idiopathic gout, wrist M10.031 Idiopathic gout, right wrist M10.032 Idiopathic gout, left wrist M10.039 Idiopathic gout, unspecified wrist M10.04 Idiopathic gout, hand M10.041 Idiopathic gout, right hand M10.042 Idiopathic gout, left hand M10.049 Idiopathic gout, unspecified hand

M10.05 Idiopathic gout, hip M10.051 Idiopathic gout, right hip M10.052 Idiopathic gout, left hip M10.059 Idiopathic gout, unspecified hip M10.06 Idiopathic gout, knee M10.061 Idiopathic gout, right knee M10.062 Idiopathic gout, left knee M10.069 Idiopathic gout, unspecified knee M10.07 Idiopathic gout, ankle and foot M10.071 Idiopathic gout, right ankle and foot M10.072 Idiopathic gout, left ankle and foot M10.079 Idiopathic gout, unspecified ankle

and foot M10.08 …… vertebrae M10.09 …… multiple sites M10.1 Lead-induced gout M10.10 …… unspecified site M10.11 Lead-induced gout, shoulder M10.111 Lead-induced gout, right shoulder M10.112 Lead-induced gout, left shoulder M10.119 Lead-induced gout, unspecified

shoulder

Listing of Gout in ICD-10

M10.12 Lead-induced gout, elbow M10.121 Lead-induced gout, right elbow M10.122 Lead-induced gout, left elbow M10.129 Lead-induced gout, unspecified

elbow M10.13 Lead-induced gout, wrist M10.131 Lead-induced gout, right wrist M10.132 Lead-induced gout, left wrist M10.139 Lead-induced gout, unspecified wrist M10.14 Lead-induced gout, hand M10.141 Lead-induced gout, right hand M10.142 Lead-induced gout, left hand M10.149 Lead-induced gout, unspecified

hand M10.15 Lead-induced gout, hip M10.151 Lead-induced gout, right hip M10.152 Lead-induced gout, left hip M10.159 Lead-induced gout, unspecified hip M10.16 Lead-induced gout, knee M10.161 Lead-induced gout, right knee M10.162 Lead-induced gout, left knee M10.169 Lead-induced gout, unspecified

knee

M10.17 Lead-induced gout, ankle and foot M10.171 Lead-induced gout, right ankle and foot M10.172 Lead-induced gout, left ankle and foot M10.179 Lead-induced gout, unspecified ankle and

foot M10.18 …… vertebrae M10.19 …… multiple sites M10.2 Drug-induced gout M10.20 …… unspecified site M10.21 Drug-induced gout, shoulder M10.211 Drug-induced gout, right shoulder M10.212 Drug-induced gout, left shoulder M10.219 Drug-induced gout, unspecified shoulder M10.22 Drug-induced gout, elbow M10.221 Drug-induced gout, right elbow M10.222 Drug-induced gout, left elbow M10.229 Drug-induced gout, unspecified elbow M10.23 Drug-induced gout, wrist M10.231 Drug-induced gout, right wrist M10.232 Drug-induced gout, left wrist M10.239 Drug-induced gout, unspecified wrist M10.24 Drug-induced gout, hand M10.241 Drug-induced gout, right hand M10.242 Drug-induced gout, left hand M10.249 Drug-induced gout, unspecified hand

Listing of Gout in ICD-10

M10.25 Drug-induced gout, hip M10.251 Drug-induced gout, right hip M10.252 Drug-induced gout, left hip M10.259 Drug-induced gout, unspecified hip M10.26 Drug-induced gout, knee M10.261 Drug-induced gout, right knee M10.262 Drug-induced gout, left knee M10.269 Drug-induced gout, unspecified knee M10.27 Drug-induced gout, ankle and foot M10.271 Drug-induced gout, right ankle and foot M10.272 Drug-induced gout, left ankle and foot M10.279 Drug-induced gout, unspecified ankle and

foot M10.28 …… vertebrae M10.29 …… multiple sites M10.3 Gout due to renal impairment M10.30 …… unspecified site M10.31 Gout due to renal impairment, shoulder M10.311 Gout due to renal impairment, right shoulder M10.312 Gout due to renal impairment, left shoulder M10.319 Gout due to renal impairment, unspecified

shoulder M10.32 Gout due to renal impairment, elbow M10.321 Gout due to renal impairment, right elbow M10.322 Gout due to renal impairment, left elbow M10.329 Gout due to renal impairment, unspecified

elbow

M10.33 Gout due to renal impairment, wrist M10.331 Gout due to renal impairment, right wrist M10.332 Gout due to renal impairment, left wrist M10.339 Gout due to renal impairment, unspecified

wrist M10.34 Gout due to renal impairment, hand M10.341 Gout due to renal impairment, right hand M10.342 Gout due to renal impairment, left hand M10.349 Gout due to renal impairment, unspecified

hand M10.35 Gout due to renal impairment, hip M10.351 Gout due to renal impairment, right hip M10.352 Gout due to renal impairment, left hip M10.359 Gout due to renal impairment, unspecified hip M10.36 Gout due to renal impairment, knee M10.361 Gout due to renal impairment, right knee M10.362 Gout due to renal impairment, left knee M10.369 Gout due to renal impairment, unspecified

knee M10.37 Gout due to renal impairment, ankle and foot M10.371 Gout due to renal impairment, right ankle and

foot M10.372 Gout due to renal impairment, left ankle and

foot M10.379 Gout due to renal impairment, unspecified

ankle and foot M10.38 …… vertebrae M10.39 …… multiple sites

Listing of Gout in ICD-10

M10.4 Other secondary gout M10.40 …… unspecified site M10.41 Other secondary gout, shoulder M10.411 Other secondary gout, right shoulder M10.412 Other secondary gout, left shoulder M10.419 Other secondary gout, unspecified

shoulder M10.42 Other secondary gout, elbow M10.421 Other secondary gout, right elbow M10.422 Other secondary gout, left elbow M10.429 Other secondary gout, unspecified

elbow M10.43 Other secondary gout, wrist M10.431 Other secondary gout, right wrist M10.432 Other secondary gout, left wrist M10.439 Other secondary gout, unspecified

wrist M10.44 Other secondary gout, hand M10.441 Other secondary gout, right hand M10.442 Other secondary gout, left hand M10.449 Other secondary gout, unspecified

hand M10.45 Other secondary gout, hip M10.451 Other secondary gout, right hip

M10.452 Other secondary gout, left hip M10.459 Other secondary gout, unspecified hip M10.46 Other secondary gout, knee M10.461 Other secondary gout, right knee M10.462 Other secondary gout, left knee M10.469 Other secondary gout, unspecified knee M10.47 Other secondary gout, ankle and foot M10.471 Other secondary gout, right ankle and

foot M10.472 Other secondary gout, left ankle and foot M10.479 Other secondary gout, unspecified ankle M10.452 Other secondary gout, left hip M10.459 Other secondary gout, unspecified hip M10.46 Other secondary gout, knee M10.461 Other secondary gout, right knee M10.462 Other secondary gout, left knee M10.469 Other secondary gout, unspecified knee M10.47 Other secondary gout, ankle and foot M10.471 Other secondary gout, right ankle and

foot M10.472 Other secondary gout, left ankle and foot M10.479 Other secondary gout, unspecified ankle M10.48 …… vertebrae M10.49 …… multiple sites M10.9 Gout, unspecified

Listing of Gout in ICD-10

Morbid obesity is a commonly used term used to refer to patients whose body weight is between 50%-100% and 100 pounds or more than the normal body weight. Obese patients are normally identified with a body mass index of 39.

In 2009-2010, a report stated that the prevalence of obesity among American men and women was nearly 36 percent.

Additionally, approximately 17 percent (or 12.5 million) of children and adolescents aged 2-19 years are obese.

Obesity

For correct coding of overweight and obesity, documentation should include: Severity — Terms such as overweight, obese, or

morbid obesity;

Contributing factors — Such as excessive calories or “drug induced”;

Association — Of any Pregnancy

Symptoms/Findings/Manifestations — Documentation of BMI or Alveolar hypoventilation

Documentation

BMI is the measurement of body fat based on height and weight. Obesity is diagnosed when a person’s BMI is 30 or higher. Body mass index is calculated by dividing weight in kilograms (kg) by height in meters (m) squared.

Use Additional code to identify (BMI), if known (Z68.-)

Category BMI

Underweight Below 18.5

Normal 18.5-24.9

Overweight 25.0-29.9

Obesity 30.0 and above

E66 Overweight and obesity E66.0 Obesity due to excess calories E66.01 Morbid (severe) obesity due to

excess calories E66.09 Other obesity due to excess calories E66.1 Drug-induced obesity E66.2 Morbid (severe) obesity with alveolar

hypoventilation E66.3 Overweight E66.8 Other obesity E66.9 Obesity, unspecified

Code Choices

Overweight and obesity E66- Code First obesity complicating pregnancy,

childbirth and the puerperium, if applicable (O99.21-)

Use Additional code to identify body mass index (BMI), if known (Z68.-)◦ Type 1 Excludes:

adiposogenital dystrophy (E23.6) lipomatosis NOS (E88.2) lipomatosis dolorosa [Dercum] (E88.2) Prader-Willi syndrome (Q87.1)

E66 contains two instructional notes:

Encounter for general adult medical examination without abnormal findings:

Z00.00 is a billable ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Used for encounters for adult health check-up NOS

Z00.01 - Encounter for general adult medical examination with abnormal findings,

Z01.411 - Encounter for gynecological examination (general) (routine) WITH abnormal findings,

Z01.419 - Encounter for gynecological examination (general) (routine) WITHOUT abnormal findings.

Routine Exams

When reporting a gynecological exam, you may report additional codes:

◦ screening for human papillomavirus (Z11.51), ◦ screening vaginal Pap smear (Z12.72), or ◦ acquired absence of uterus (Z90.71), if applicable.

If you provide a screening pap smear for malignant neoplasm of the cervix outside of a gynecological exam, you would report that with code Z12.4.

It is not necessary to report code Z12.4 when the screening takes place as part of a gynecological exam (Z01.411 or Z01.419).

Adult Annual Exam

Codes for newborn health exams:◦ Use Z00.110 for a newborn under 8 days old◦ Z00.111 for a newborn 8 to 28 days old. ◦ For children 29 days old and older:

Use one of two codes: Z00.121, Encounter for routine child health examination

WITH abnormal findings. Diagnosis codes for abnormal findings should be coded regardless of whether the finding requires an additionally reportable service.

or Z00.129, Encounter for routine child health examination

WITHOUT abnormal findings.

Well-child Exam

ICD-10 allows you to report code Z23 for a visit involving immunization regardless of the type or number of vaccines.

With ICD-9, you have to report V04.81 for the influenza vaccine alone or V06.6 if you provide both the influenza vaccine and the pneumonia vaccine on the same date.

With ICD-10, you just code Z23 regardless of how many or what types of vaccines are administered.

◦ The Z23 code includes the following note: “Code first any routine childhood examination.”

◦ Therefore, when you provide immunizations with a well-child visit, a code for routine child health examination should be reported first, followed by Z23 for any immunizations. (similar to ICD-9).

Immunizations

Your code selection for a routine examination of the eyes and vision will also depend on whether you have identified any abnormal findings. The codes are as follows: Z01.00, Encounter for examination of eyes

and vision without abnormal findings, Z01.01, Encounter for examination of eyes

and vision with abnormal findings.

Vision Exam

Code selection depends on whether there has been any abnormal findings identified or whether the patient has already failed a hearing screening. Code options are as follows: Z01.10, Encounter for examination of ears

and hearing WITHOUT abnormal findings, Z01.110, Encounter for hearing examination

following FAILED hearing screening, Z01.118, Encounter for examination of ears

and hearing WITH other abnormal findings

Hearing Exam

Colorectal cancer screening:V76.51 Screening malignant neoplasm colon

Diabetes screeningV77.1 Screening for diabetes mellitus

Human immunodeficiency virus screeningV73.89 Screening for other specified viral diseases

Z12.11 Encounter for screening for malignant neoplasm of colon

Z13.1 Encounter for screening for diabetes mellitus

Z11.4 Encounter for screening for HIV

Crosswalk for Screening

Osteoporosis screeningV82.81 Screening for osteoporosis

Prostate cancer screeningV76.44 Screening for malignancy prostate

Sexually transmitted infection (STI) screening and high intensity behavioral counseling to prevent STIs

V74.5 Screening for venereal disease

V69.8 Other problems related to lifestyle

V73.89 Screening for other specified viral disease

V73.88 Screening for other specified chlamydial disease

Z13.820 Encounter for screening for osteoporosis

Z12.5 Encounter for screening for malignant neoplasm of prostate

Z11.3 Encounter for screening for infections with a predominantly sexual mode of transmission

Z72.89 Other problems related to lifestyle

Z11.59 Encounter for screening for other viral diseases

Z11.8 Encounter for screening for other infectious and parasitic diseases (e.g., chlamydia)

Crosswalks

Obesity: ICD-10-CM Code Assignment: by John Verhovshek, MA, CPC

Code It Right online May 23, 2013 Cindy Hughes, CPC, CFPC - FPM's ICD-10

coding series continues with a look at how to code immunizations, routine health exams, and common preventive screenings.

Fam Pract Manag. 2014 Jul-Aug;21(4):OA1-OA4.

References

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