ICD-10 essentials for busy physicians who would rather be doing something else – arthritis and back pain


This blog is nominally for rheumatologists. They are the ones who end up treating long-term sufferers of painful musculoskeletal conditions, especially those with autoimmune origins. But since a significant number of people suffer from arthritis or back pain, and most of them see most of you for various reasons, this basic ICD-10 information may be of interest.

Arthritis -- Rheumatoid et al
It is still fashionable to get worked up about the number of ICD-10 codes, stating that, contrary to every other aspect of the information age, more is worse. People who have jumped on this bandwagon tend to use examples of codes that are statistically rare and of no relevance whatsoever to most physician practices (external cause codes for exotic animal bites and wildly improbable boating accidents, etc.). They leap blithely from their favorite silly ICD-10 code to the conclusion that ICD-10 contains no new clinically relevant detail.

I’d like to do my usual unfashionable thing again, and show you a bunch of new rheumatoid arthritis codes in ICD-10. Judge for yourself whether the ICD-10 detail is clinically relevant.

In ICD-9 there is one code for rheumatoid arthritis. One measly code -- 714.0, Rheumatoid arthritis. Imagine -- a patient’s three-decade struggle with rheumatoid arthritis in all its specific manifestations. That person’s story is told using the same two words repeated over and over in 30 years’ worth of ICD-9 data -- rheumatoid arthritis. The extreme Cliff’s Notes version from hell.

In ICD-10 there are 190 codes. Yes, I know -- holy cow and so forth. But as with many musculoskeletal disorders, the proliferation of codes results from the consistent application of a new axis of classification to further define a condition. There are two new axes added to the rheumatoid arthritis classification. They are listed below with the specific labels in the rheumatoid arthritis category used to create unique codes that describe the patient’s condition.

Manifestation and/or presence of rheumatoid factor

  • Rheumatoid arthritis with
  • Bursitis
  • Myopathy
  • Nodule
  • Polyneuropathy
  • Other organ or system involved (e.g., lung, pericardium)
  • Rheumatoid factor without organ or system involvement
  • Other manifestation with rheumatoid factor
  • Rheumatoid arthritis NEC

Joint affected (includes left, right and unspecified options)

  • Shoulder
  • Elbow
  • Wrist
  • Hand
  • Hip
  • Knee
  • Ankle or foot
  • Multiple sites
  • Vertebrae (in select subcategories only)
  • Unspecified site

Multiply these choices out and you get a rough idea how one code expands to 190 codes. Note that if the individual has involvement of wrists, hands and ankles, it is permissible to use “multiple sites” rather than coding each joint individually.

So, is this level of detail about rheumatoid arthritis useful? For instance, would it help with medical necessity for rheumatoid arthritis treatment options, or larger scale investigations of what treatment works best for certain manifestations? I don’t know. I am asking you.

And remember, there is always an unspecified ICD-10 code, for those who don’t have more information on the patient’s condition. The unspecified rheumatoid arthritis option is M06.9 Rheumatoid arthritis, unspecified.

Other types and etiologies of arthritis are not so dramatically expanded, but they do specify more detail and do so more clearly. For example, for many joint disorder codes ICD-9 did not use the name of the joint in the code description. For some bizarre reason they call the hip joint “pelvic region and thigh” and the knee joint “lower leg.” In ICD-10 descriptions, a hip is a hip and a knee is a knee. You also have the ability to specify arthritis of the left or right or both joints, as in the knee example below.

715.16 Osteoarthrosis, localized, primary, lower leg  

Is replaced by

M17.0 Bilateral primary osteoarthritis of knee 
M17.10 Unilateral primary osteoarthritis, unspecified knee 
M17.11 Unilateral primary osteoarthritis, right knee 
M17.12 Unilateral primary osteoarthritis, left knee

Back and neck pain
Many people in this country experience chronic back pain, and don’t get a more specific diagnosis like HNP or spinal stenosis until they get serious about surgical intervention. This means your documentation and coding options are limited to symptom codes specifying the pain by spinal region. The “dorsalgia” codes have been moved from the symptom chapter to the musculoskeletal chapter in ICD-10 (think M for Musculoskeletal, since it happens to match in ICD-10) but that is really a housekeeping detail. The codes themselves have not changed radically. They just contain better codes for specifying site. For example, sciatica. You can now specify whether the sciatica is on the left or right side. If a patient has documented sciatica with low back pain, you can now capture this condition using unique codes. If the condition occurs on both sides, you can code both left and right codes for the encounter. Examples appear below.

M54.30 Sciatica, unspecified side
M54.31 Sciatica, right side
M54.32 Sciatica, left side  
M54.40 Lumbago with sciatica, unspecified side
M54.41 Lumbago with sciatica, right side 
M54.42 Lumbago with sciatica, left side  

Replace

724.3 Sciatica

In addition, there is a unique code for occipital neuralgia. In ICD-9 this condition was captured with a catch-all code of dubious usefulness.

M54.81 Occipital neuralgia

Replaces

723.8 Other syndromes affecting cervical region

Talking about back pain has whetted my appetite for looking at ICD-10 codes for more definitive spinal conditions that can result in a referral to the orthopedic surgeon’s office. So look for that next time.

Rhonda Butler is a senior clinical research analyst with 3M Health Information Systems. She is responsible for the development and maintenance of the ICD-10 Procedure Coding System since 2003 under contract to CMS, and for the development and maintenance of the ICD-10 General Equivalence Mappings (GEMs) and Reimbursement Mappings under contract to CMS and the CDC.  She leads the 3M test project to convert the MS-DRGs to ICD-10 for CMS, and is on the team to convert 3M APR-DRGs to ICD-10. Rhonda also writes for the 3M Health Information Systems blog.

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