advise -unspec meniscus tears

PLAIDMAN

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I am really unsure how to code dx for meniscus tears that are not spec. as current / vs/ old

I have no indications what so ever if injury took place/ or not in op reports - DR WILL NOT correct/addend/specify

I have to put some kind of code on it ?

should i use an unspec internal derangement code ? this is where i am leaning

any help is appreciated !
thx
 

Orthocoderpgu

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I have this issue as well. You basically need to determine if the meniscus is torn due to an injury, or just through wear and tear. Since you have no documentation that an injury has taken place, I would use the M23.XXX codes. The bigger problem is your doc. Things are changing and your doc needs to improve documentation. Otherwise, he's going to be giving back a lot of money during audits and there are much more audits now than have ever been. And as we transition to "Value based" medical reimbursement, this will be more critical for your doc. Good luck!
 

shecodes

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It was my understanding that if the documentation does not specify whether acute or chronic, that it defaults to current trauma.

With that being said, it's a great educational opportunity for the provider.
 

CodingKing

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It was my understanding that if the documentation does not specify whether acute or chronic, that it defaults to current trauma.

With that being said, it's a great educational opportunity for the provider.

Usually goes to whatever is the default code.

However there is a guideline re Acute Traumatic vs Chronic or recurrent musculoskeletal conditions and query the physician is the correct answer here

I.C.13.b

b. Acute traumatic versus chronic or recurrent musculoskeletal conditions
Many musculoskeletal conditions are a result of previous injury or
trauma to a site, or are recurrent conditions. Bone, joint or muscle
conditions that are the result of a healed injury are usually found in
chapter 13. Recurrent bone, joint or muscle conditions are also usually
found in chapter 13. Any current, acute injury should be coded to the
appropriate injury code from chapter 19. Chronic or recurrent
conditions should generally be coded with a code from chapter 13. If it
is difficult to determine from the documentation in the record which
code is best to describe a condition, query the provider
 

shecodes

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Usually goes to whatever is the default code.

However there is a guideline re Acute Traumatic vs Chronic or recurrent musculoskeletal conditions and query the physician is the correct answer here

I.C.13.b

My response was taking into consideration that the original poster stated that the provider is uncooperative, implying the provider has been queried unsuccessfully.

There is also a guideline re Default codes when dealing with a lack of information. Default code S83.209*

I.A.18

Default codes
A code listed next to a main term in the ICD-10-CM Alphabetic Index is referred to as a default code. The default code represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition. If a condition is documented in a medical record (for example, appendicitis) without any additional information, such as acute or chronic, the default code should be assigned.
 
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