Wiki RA Coding - Unspecified Joint Pain

[Redscooter]

The doctor uses pain in unspecified joint. Shouldn't the dx be specific to the joints she mentions in HPI? (M25.562, M25.561, M25.542, M25.541, M79.671, M79672)

New Patient

DX:
M25.50 - Pain in unspecified joint
M19.90 - Unspecified osetoarthritis, unspecified site
CHIEF COMPLAINT:
Joint Pain

HISTORY OF PRESENT ILLNESS:
The patient is a 75 y.o. female who is here in our clinic with chief complaint of Joint Pain. Patient reports known history of gout flare-ups in the recent past. She reports most recently she has been having joint pain in both her hands and her feet. She also complains of pain in her knees. She has morning time stiffness lasting for 2 hours. She has noticed obvious joint swelling in her hands. Denies exacerbating or alleviating factors. Associated symptoms include fatigue. She denies known history of serositis, DVT, PE, seizure or stroke. Denies Alopecia, Raynaud's, dry eyes, dry mouth, oral ulcers, malar rash, photosensitivity, history of uveitis, vision loss, jaw claudication, temporal headaches, fevers, chills, night sweats, recent weight loss, myalgias or rashes.

REVIEW OF SYSTEMS:
Constitutional: Negative for fevers, chills, loss of appetite or weight loss.
Eyes: Negative for dry eyes, diplopia, and conjunctivitis.
ENT: Negative for oral ulcers, dry mouth, sore throat, sinus drainage, hearing difficulties, headaches and jaw pain.
Cardiovascular: Negative for chest pain and palpitations.
Respiratory: Negative for cough and hemoptysis.
Gastrointestinal: Negative for nausea, vomiting, diarrhea, bloody stools and heartburn.
Integumentary: Negative for rash, hives, nodules, unusual loss of hair, malar rash or photosensitivity.
Neurologic: Negative for sensory problems.
Endocrine/Exocrine: Negative for polydipsia, polyuria or swollen glands.
Hematologic/Lymphatic: Negative for tender or palpable lymph nodes.
Psychiatric: Negative for anxiety.
Musculoskeletal: Negative for muscle pain or cramps.
IMPRESSION AND PLAN:
The patient is a 75 y.o. female seen in our clinic for initial evaluation for Polyarthralgia's. I have been asked to see this patient because of gout. Patient does complain of poly articular joint pains have high suspicion for inflammatory arthritis. I will do initial diagnostic workup as listed below.


1)Polyarthralgia: I will obtain labs and xrays today to rule out any inflammatory condition.

2)Osteoarthritis: Will get Xrays today.

3) Fatigue: I will rule out any other contributing factors at this time.

4)Hypovitaminosis D: I will check level today and replace as needed.

Diagnoses and all orders for this visit:

Was seen today for joint pain.

Diagnoses and all orders for this visit:

Polyarthralgia (Primary)
- C-Reactive Protein; Future
- CBC without Differential; Future
- Comprehensive Metabolic Panel; Future
- Sedimentation Rate, Automated
- Cyclic Citrullinated Peptide IgG
- Rheumatoid Factor Quantitative
- ANA IFA Reflex Panel
- X-Ray Chest PA and Lateral
- X-Ray Foot Left AP Lateral and Oblique
- X-Ray Foot Right AP Lateral and Oblique
- X-Ray Hand Left PA Lateral and Oblique
- X-Ray Hand Right PA Lateral and Oblique
- X-Ray Knee Left AP Lateral and Axial
- X-Ray Knee Right AP Lateral and Axial
- X-Ray Elbow Left AP and Lateral
- C-Reactive Protein
- CBC without Differential
- Comprehensive Metabolic Panel

Osteoarthritis, unspecified osteoarthritis type, unspecified site
- C-Reactive Protein; Future
- CBC without Differential; Future
- Comprehensive Metabolic Panel; Future
- Sedimentation Rate, Automated
- Cyclic Citrullinated Peptide IgG
- Rheumatoid Factor Quantitative
- ANA IFA Reflex Panel
- X-Ray Chest PA and Lateral
- X-Ray Foot Left AP Lateral and Oblique
- X-Ray Foot Right AP Lateral and Oblique
- X-Ray Hand Left PA Lateral and Oblique
- X-Ray Hand Right PA Lateral and Oblique
- X-Ray Knee Left AP Lateral and Axial
- X-Ray Knee Right AP Lateral and Axial
- X-Ray Elbow Left AP and Lateral
- C-Reactive Protein
- CBC without Differential
- Comprehensive Metabolic Panel

 

[altman76]

If the specificity is clear in the medical record for that visit, yes it definitely should be billed with the specificity defined by the ICD-10 code. We bill our provider's diagnosis code with the specific location when the record reflects a right or left, upper or lower, etc. Unspecified codes for laterality are starting to become a common denial with some major insurances, thus diving down to the exact location of what is being treated (if documented) is very important.

 

[Redscooter]

Thank you!