Orthopedic Coding Alert
Add Synonyms to Your Dx Coding Arsenal
Question: Encounter notes indicate that the provider performed an office/ outpatient evaluation and management (E/M) service for an established patient with “supraspinatus synd, R shoulder.” Encounter time was 33 minutes and involved low medical decision making (MDM). How should I code this encounter? I don’t know what supraspinatus syndrome is, or how to choose an ICD-10 code for it. Missouri Subscriber Answer: For the E/M, report 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.). Since you can code office/outpatient E/Ms based on time or MDM, you should choose the component that results in a higher E/M level; in this case, time. Remember that there’s nothing wrong with this practice — as long as you are coding to the notes. Dx coding: You might not know the term supraspinatus syndrome, but you’ve probably heard other terms used for the injury. ICD-10 officially recognizes the M75.1- (Rotator cuff tear or rupture, not specified as traumatic) code set for supraspinatus syndrome. Other terms ICD-10 considers synonymous with the M75.1- descriptor are “rotator cuff syndrome” and “supraspinatus tear or rupture, not specified as traumatic.” Your coding adventure doesn’t stop there, though, as you still have to drill down to get the most accurate code possible for this patient’s injury. Go back and look at the notes again, which will direct you to M75.10- (Unspecified rotator cuff tear or rupture, not specified as traumatic); then, choose one of the following ICD-10 codes for the patient’s injury: 
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