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.