ICD-10: Coding Snapshot

HISTORY OF PRESENT ILLNESS: The patient is a 38-year-old woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than two years duration. The patient states that she began with right hip pain getting steadily worse over the last two years, and then developed some pain in the left hip. The pain is located laterally as well as anteriorly into the groin. She states that the pain is present during activities such as walking, and she does get some painful popping and clicking in the right hip. She is here for evaluation for the first time. She sought no previous medical attention for this.

CURRENT MEDICATIONS: Listed in the chart and reviewed with the patient.

ALLERGIES: The patient has no known drug allergies.

SOCIAL HISTORY: The patient is married. She is employed as an office manager. She is a cigarette smoker with a one pack, per day for the last 20 years dependence. She consumes alcohol three to five drinks, weekly. She uses no illicit drugs. She exercises monthly, mainly walking and low impact aerobics. She also likes to play softball.

REVIEW OF SYSTEMS: Significant for occasional indigestion and nausea. The remainder of the systems negative.

PHYSICAL EXAMINATION: The patient is 5 foot, 2 inches tall, weighs 155 pounds. The patient ambulates independently without an assist device with normal stance and gait. Inspection of the hips reveals normal contour and appearance and good symmetry. The patient is able to do an active straight leg raise against gravity and against resistance bilaterally. She has no significant trochanteric tenderness. She does, however, have some tenderness in the groin bilaterally. There is no crepitus present with passive or active range of motion of the hips. She is grossly neurologically intact in the bilateral lower extremities.

DIAGNOSTIC DATA: X-rays performed today in the clinic include an AP view of the pelvis and a frog-leg lateral of the right hip. There are no acute findings. No fractures or dislocations. There are minimal degenerative changes noted in the joint. There is, however, the suggestion of an exostosis on the superior femoral neck, which could be femoroacetabular impingement.

IMPRESSION: Chronic bilateral hip pain, right worse than left, possibly suggesting femoroacetabular impingement based on X-rays. Her clinical picture is also consistent with possible labral tear.

PLAN: After discussing possible diagnoses with the patient, I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy and especially concentrating on the labrum in the right hip. We will get that done as soon as possible. In the meantime, she is asked to moderate her activities. She will follow up as soon as the MRIs are performed.

ICD-10-CM Code(s):        M25.561 Pain in right knee

                                         M25.562 Pain in left knee

                                         G89.29 Other chronic pain

Rationale: The patient presents for evaluation of bilateral chronic knee pain. Diagnostic data and the Impression list two possible reasons (femoroacetabular impingement and labral tear). As these are not confirmed, the knee pain is coded. There is no bilateral code for knee pain in ICD-10-CM; therefore, two codes are necessary to indicate both knees are affected. The fact that the knee pain is chronic is not addressed in the codes for knee pain. Codes in category G89 in ICD-10-CM are for Pain, not elsewhere classified, including acute and chronic pain.

According to the guidelines, codes from category G89 can be used with codes from other categories and chapters to provide more detail about acute or chronic pain. The sequencing of the codes will depend on the reason for the encounter. Guideline I.C.6.b.1.b.i states that G89 codes should be used with site-specific codes if it adds more detail. In this case, the site-specific codes do not address the temporal parameter of the pain (chronic). Guideline and I.C.6.1.b.ii states that if the patient is presenting for pain control or pain management, then the G89 code should be sequenced first. For any other reason, the site-specific pain code should be sequenced first. In this case, the patient presents for evaluation, not for pain management, so the knee pain codes are sequenced first.

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Brad Ericson

Brad Ericson

Publisher at AAPC
Brad Ericson, MPC, CPC, COSC, has been publisher for more than nine years. Before AAPC he was at Optum for 13 years and at Aetna Health Plans before that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.
Brad Ericson

About Has 197 Posts

Brad Ericson, MPC, CPC, COSC, has been publisher for more than nine years. Before AAPC he was at Optum for 13 years and at Aetna Health Plans before that. He has been writing and publishing about healthcare since 1979. He received his Bachelor's in Journalism from Idaho State University and his Master's of Professional Communication degree from Westminster College of Salt Lake City.

19 Responses to “ICD-10: Coding Snapshot”

  1. MARILYNN MCDORMAN says:

    WHY IS THE DIAGNOSIS FOR KNEE PAIN WHEN SHE PRESENTED WITH HIP PAIN? THE EXAM AND XRAYS WERE ON HER HIPS NOT HER KNEES.

  2. Mary Kubacki says:

    The patient presented with hip pain. Why would you code out knee pain?

  3. Carolyn Devers says:

    I agree with the other comments as to why knee codes when the patient presents with hip pain. Was this a test??

  4. Sharon K says:

    Ditto, please proof read your scenarios.

  5. Tammy Harris says:

    Was this a done on purpose to see if we could find the error? The documentation clearly states that it’s about the hips and not the knees.

  6. Ronald Gfell says:

    Hips not knees should be coded.
    coding should be m25.551, m25.552, G89.29
    Please correct and repost this scenario
    thanks

  7. Sharon K says:

    you forgot the tobacoo dependence and the smoking and the BMI codes.

  8. Dawn says:

    Apparently this was not reviewed before posting, as there is a HUGE discrepancy in pain location. Even a newbie coder would’ve picked that up. C’mon AAPC, quality control.

  9. Rose G says:

    Agreed, why bother with detail?

  10. Hina Balapurwala says:

    The patient presented with hip pain. Why,code for knee pain.

  11. Inge Holcomb says:

    Really, so all these years I have been trying to teach students anatomy and physiology and now the hips have moved to the knees. Must be gravitity. Quality control?

  12. Tamara says:

    I just got my cpc certification in december of 2014, and i knew something was not right with that scenario. The patient mentioned nothing about knee pain. Hip pain was her chief complaint. I am focus.

  13. Pamela Davis says:

    THE CODES ATTACHED TO PATIENT REASON FOR VISIT ADDRESS THE KNEE AND THE PATIENT NEVER MENTIONED HER KNEE NOR ARE ANY OF THE NOTES FROM THE DOCTOR ADDRESS THE KNEE.
    SO, HOW IS IT THE ICD-10 ASSIGN CODES DIRECTED TO THE KNEE? BECAUSE THE FIRST RULE OF CODING IS WE FIRST CODE REASON FOR VISIT THEN ANY COMMENT NOTES FROM THE PHYSICIAN. THEREFORE THE CODES REGARDING THIS PATIENTS VISIT WOULD NOT BE CORRECT.

  14. Pamela Davis says:

    THE CODE ASSIGNNED VIA ICD-10 BREAK THE FIRST RULE OF CODING. THE PATIENT NEVER MENION HER KNEE AND THE DOCTOR MADE NO NOTATION REGARDING HER KNEE THEREFORE, THE CODE ASSINGNED IS INCORRECT.

  15. Julie Pisacane says:

    If this is an initial encounter wouldn’t the diagnosis code included the A as the 7th character. Tobacco codes as part of her history were listed and as the others have addressed the patient presents with primary complaints of hip pain .

    Please advise why knee codes were used.

    Thank you,

  16. Lisa Whitaker says:

    Glad to see I am not alone. There is nothing in this scenario that suggests knee pain.

  17. Elizabeth says:

    I agree, there is an error and it should be hip pain. Maybe someone had a bad day, nice to see that fellow AAPC coders caught this error! I do not see any relevance to code the smoking. Just because documentation states patient is a smoker or was in the past, there are rules for when it is appropriate to code it. If I overlooked something, please advise. Thank you.

  18. Cheryl says:

    I am with the rest of you. Confused on the diagnosis for hips when the patient presented with knee pain.

  19. Ejay Dee says:

    Okay, let’s not be smart alecks. The author knows better than having coded it as knee when the scenario is of the hip.
    We all know that the author meant to use the hip pain code and may have just punched in the knee code. One can easily make that mistake–especially when what is being emphasized here is not the anatomical area but the fact that there is NO BILATERAL codes and how CHRONIC cases may be coded using G89.29. One comment to correct is enough. Why would everyone have to put their 2-bits in, especially from that person who says he/she teaches anatomy. Why make a sarcastic comment. That is an arrogant statement from a person who would know a little but brags to know more. Even one with a board certified medical profession will not make such a comment. An apology to the author from you should be in order if you are truly an intellect.

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