Orthopedic Coding Alert

Know your anatomic terms and you-ll find the right diagnosis codes every time

If you don't know what differentiates an acute condition from a chronic one, or what separates an active injury from lingering pain, you could find yourself in a bind. Check out the following four frequently asked questions to get quick tips to help your ICD-9 coding.

Is DDH Subluxation or Dislocation?

Question #1: Our surgeon saw a baby with developmental dislocation of the hip (DDH). He documented the baby's problem with the terms -subluxation- and -dislocation.- Since ICD-9 doesn't include a diagnosis code for DDH, I was planning to use a subluxation or dislocation code, but I can't decide which term applies more. What is the difference between subluxation and dislocation?

Answer: Subluxation describes a partial or incomplete dislocation, meaning that the patient has suffered partial loss of the joint's congruency, says Chris P. Galeziewski, CPC, an orthopedic coder at the Kelsey-Seybold Clinic in Houston. -Dislocation is the complete removal of the joint from the socket,- he says.

Key point: If the patient suffered congenital subluxation, he most likely had an inborn laxity or prestretching of the ligaments and/or attaching musculotendinous groups or attachments, which do not allow a total disjointing of the femoral head, Galeziewski says. Therefore, the patient did not experience a complete dislocation.

Your best coding choice for this condition would probably be 754.32 (Congenital subluxation of hip, unilateral) for unilateral DDH, or 754.33 (Congenital subluxation of hip, bilateral) if both of the patient's hips were affected.

Do Injury Codes Apply to Pain?

Question #2: I-m looking for the coding guidelines that describe when I can report code 840.4 versus 726.10 or 727.61. Our surgeon recently performed a rotator cuff repair, and his notes document -pain for the past nine months.- Someone told me that we cannot report an acute injury code for this service and that we should select another code instead. Is that accurate? 

Answer: Yes. Code 840.4 (Sprains and strains of shoulder and upper arm; rotator cuff [capsule]) is from the -injury- chapter of the ICD-9 guidebook. In your case, the patient didn't suffer an injury--instead she experienced nine months of pain that warranted the procedure.

Therefore, you should avoid 840.4 and select another code based on the rest of the surgeon's documentation, such as 727.61 (Complete rupture of rotator cuff) or 726.10 (Disorders of bursae and tendons in shoulder region, unspecified) instead.

Acute Vs. Chronic Injuries: How to Decide

Question #3: How can we differentiate an acute injury from a chronic one?

Answer: -An acute condition is sudden and severe. A chronic condition is a longer developing syndrome, persistent, continuing, or recurring, but may have been caused by an acute injury,- says Susan Vogelberger, CPC,  CPC-H, business office coordinator for the Orthopedic Surgery Center at Beeghly Medical Park in Ohio.

By definition, a patient could have both--a chronic condition resulting from an acute injury, Vogelberger says. -The American Hospital Association's official Inpatient and Outpatient Coding Rules state, -If the same condition is described as both acute (subacute) and chronic, and separate subentries exist in the alphabetical index at the same indentation level, code both and sequence the acute (subacute) code first.- They are, of course, referring to the ICD-9-CM alphabetical index,- she says.

Many practices use the -three months or longer- guideline for coding chronic conditions such as rotator cuff tears. -A definitive guideline has not been addressed by CMS, although they have identified coverage of electrical stimulation for chronic wounds as -longer than one month,- - Vogelberger says.

CDC Loosely Uses -3-Month- Guideline

In black and white: Although not all payers or physicians follow this guideline, the Centers for Disease Control's National Center for Health Statistics publishes the following definition of an acute condition:

-An acute condition is a type of illness or injury that ordinarily lasts less than three months, was first noticed less than three months before the reference data of the interview, and was serious enough to have had an impact on behavior.-

Because even -acute- tears are usually acute exacerbations of chronic tears, surgeons feel that the number of tendons the patient tears has nothing to do with which CPT code the surgeon selects (such as 23410, Repair of ruptured musculotendinous cuff [e.g., rotator cuff] open; acute versus 23412, -chronic). In most cases, surgeons can't diagnose a rotator cuff tear until the injury becomes chronic.

Bottom line: Leave the determination of acute versus chronic up to the surgeon. If an ICD-9 or CPT code forces you to differentiate between whether the patient's condition is acute or chronic, show both descriptors to the surgeon and ask him to decide.

How Many Diagnosis Codes Are -Too Many-?

Question #4: Our surgeon submitted the following operative note, but we can't determine which ICD-9 code applies. Should we report all of them or just one?
 
-A frayed and detached superior anterior labrum with detachment of the junction of the anterior superior and anterior portion of the labrum and about 90 percent detachment of the anterior aspect of the labrum right at the biceps tendon anchor. Some fraying of the posterior superior labrum but no detachment, and no detachment of the biceps tendon anchor itself. Some synovitis especially anteriorly and superiorly.

-No evidence of any rotator cuff tear. The middle glenohumeral ligament was somewhat frayed, and the patient did appear to have some subtle laxity anteriorly, increased from the opposite side both on exam under anesthesia and when viewing through the arthroscope. The remainder of the patient's labrum appeared normal. The subacromial space appeared without any significant synovitis, and the rotator cuff looked intact looking at it superiorly.-

Answer: If the patient suffered shoulder joint instability, you should report 718.81 (other joint derangement, not elsewhere classified, shoulder region). If not, you should use 719.91 (unspecified disorder of joint; shoulder region) instead. ICD-9 does not include any specific codes for labral lesions.

Some coding experts also recommend adding the diagnosis code 718.01 (Articular cartilage disorder; shoulder region) to your claim. In addition, you can add 840.7 (Sprains and strains of shoulder and upper arm; superior glenoid labrum lesion) for the labral tear, because the documentation notes up to 90 percent detachment of the labrum. Ensure, however, that the documentation includes an injury date before you add this code.

Although the insurer's computer will only scan the first, main diagnosis code listed, it is a good idea to list all of the codes that apply. That way, if the payer challenges a claim, you can help your appeal by having already sent the insurer all the applicable diagnoses on record for the patient.