Wiki Need DX code for ACL Deficient Knee

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micki127

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Hello,

Does anyone have a suggestion for ACL Deficient Knee (right)? Not sure if M23.51 is accurate.

Thank you in advance!
Micki
 
Did you ever find out the Dx for ligament deficiency?

Peace
?_?
We just use M23.61_ for ACL deficiency and M23.62_ for PCL deficiency.
 
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Unfortunately, I don't think that M23.61 _ or .62 _ fill the bill for this "Diagnosis," since M23.6 is for Other Spontaneous disruption of ligaments, with the emphasis on "Spontaneous." For practical purposes, the "Spontaneous" rupture of any ligament is extremely rare, particularly the Cruciate Ligaments. These are going to be traumatic essentially every time. The term "ACL (or PCL) Deficient Knee" refers to a knee in which the ACL(PCL) is believed or known to be absent (i.e. a nonfunctioning ligament), particularly if the physical examination reveals/fulfills all the exam criteria for the "Diagnosis." Usually the MRI will also confirm damage or tearing of the ACL(PCL) of varying degrees of severity. The term usually applies to Chronic situations, but in some circumstances could be used in Subacute situations, rarely Acute. So the "translation" of the diagnosis "ACL(PCL, etc.) Deficient Knee" is "Chronic/Old Tear of the ACL(PCL) Ligament."
As for other possible codes, M23.5 _ is for Chronic instability of the Knee, which is "technically" correct, but very non-specific in that it doesn't identify any of the ligaments of the knee, singularly or in combination, that would account for the specific type of "instability/insufficiency" that would be accurate/correct. M24.2: Disorder of the ligament is a code set that includes "Chronic Instability secondary to Old Ligamentous Injury." For reasons beyond my comprehension, in the ICD-10 Coding Manuals by Optum, which are the only ones I have seen, the knee (5th Character 6) is left out of the list of 5th Characters that it allows for in the set. I don't know about other manuals from other sources (AHA, AAPC, etc.). As far as I am concerned, this is a big mistake and/or an "Error of Omission" by the creators/writers or publishers/printers of ICD-10. It doesn't specifically Exclude the knee, but just leaves it out. M24.26 _ (6th Character for Laterality) would be far more specific than M23.5 in that it is consistent with an "old ligamentous injury," which this condition (ACL Insufficient Knee) certainly is. Unfortunately it doesn't allow for more specificity for the ACL, PCL, MCL, LCL, etc. That would be nice, but would push the codes to 7 characters, which would only make things messier than they already are. (I'll get off of my Soapbox now.)

I hope this discussion helps you and others understand this "Diagnosis" better. You could try M24.26 _ for this on a claim, but be prepared to argue for its use. You can certainly use my argument above if it would help.

Respectfully submitted, Alan Pechacek, M.D.
icd10orthocoder.com
 
Thank you again for the input. I've mentioned to the managers here about how the M23 series regarding ligament damage are nonspecific with regards to an injury status. The S codes for knee sprains cross reference for ligament tears better and have the added benefit of the 7th character. Dr Pechacek, what's your stance on M23.8X_? Is it too vague?

Peace
@_*
I wonder why there is an "old injury" category for meniscal damage but not one for ligamentous damage.
 
Unfortunately, I doubt we will be able to solve this dilemma regarding Chronic Instability of the Knee (M23.5) and Old Ligamentous Injury (of the Knee) (M24.2) as ICD-10 is currently written. As for M23.8X _: "Other" Internal Derangements of the knee, which includes in its definition/descriptor "Laxity of the ligament of the knee," I find it also to be so non-specific and vague as to be useless, particularly as it applies to specific ligaments of the knee (ACL, PCL, etc.) and how that ligament came to be "Lax," which in and of itself is a pretty vague term. As an Orthopedic Surgeon, when I think of something being "lax," I think in terms of the joint being "loose/lax," but not specifically to a ligament. I would probably be more specific and use terms such as "ACL Instability," "MCL Instability," etc. The term "laxity" doesn't necessarily mean from an old injury, but it could. This comes down to semantics as to how the term is used as to what it means. In other words, it covers a lot of possibilities and is not very specific. Other Orthopedic Surgeons may think and use the term "laxity" differently from me, but I doubt by very much. For practical purposed, this same semantic argument can be applied to M23.5. In my opinion, both M23.5 and M23.8X are pretty useless codes.
The other stumbling block for the M23 Code Set is that it Excludes1 "current injury-See injury of the knee and lower leg (S80-89)." I suppose that if there was enough good documentation in the records to be able to clearly identify the original acute injury, evaluation, leading to a specific ligament injury diagnosis, then you might be able to go back to the original Sprain code (S83.4) and use S for the 7th Character, with the Sequela being the "Chronic Instability of the Knee due to/resulting from an Old Injury to the ? ligament." This is again where the problem of M23.5 versus M24.26 comes into play (as discussed before). But if the documentation isn't there, this would be hard to do.
As for your last comment/question for "old injury," there is an answer in M24.26_ if it could be used. (Back on my "Soapbox" again.)
I would direct your attention to the Blogs at my website, icd10orthocoder.com, where I have tried to discuss coding Knee Pain and ICD-10, including the issue of Instability. Maybe it will help too.

Respectfully, Alan Pechacek, M.D.
 
Thank you for your explanation. AETNA has posted several recent medical policies that have impacted the way claims are being processed. They entail "current" injuries from noncurrent ones. I think one of the issues with the M codes is that they have "nontraumatic" as part of the description. Thus, meniscectomies are considered experimental and not medically necessary if a M code were used regardless if the patient care has documented instances of pain and disability. I'll read up on your blog. You've always been so forthright in your communication. Thank you so much, sir.

Peace
@_*
 
Dear "Daedolos":
In ICD-10, by definition the M Codes are for Disorders of the Musculoskeletal System that are not the result of an Injury, for which the S Codes apply. The S Codes appear to apply to only Acute and Subacute injuries, i.e. present now as a result of a recent traumatic episode. This is indicated by the Exclusion of "current injury" by many M Codes when there is a question as to the origin of a chronic disorder, such as an old ligamentous injury and instability, or the possibility of an old meniscal tear that may have at one time been an acute injury. M Codes can be used for Acute and Subacute disorders except current injury, such a Acute Tendonitis, Bursitis, Joint Pain, and others (congenital/developmental). The problem is that not all "Chronic Musculoskeletal Problems/Disorders" are purely degenerative in nature/origin, but may be the long term result of an old injury (such as Post-traumatic Arthritis, M15-M19). And, "Old Injuries" can lead to/result in "Chronic Disorders," with progression over time. An old traumatic meniscal tear may not be a significant enough clinical problem as to require surgical intervention early on, but over time may do so gradually or suddenly/acutely, without necessarily being the result of a "current injury." This doesn't even allow for an "Acute on Chronic" coding possibility/opportunity. ICD-10 does very poorly at accommodating these different possibilities, particularly in the area of ligamentous and/or meniscal disorders in the knee. I addressed/discussed this dilemma in my Blog on coding knee pain problems, and gave my recommendations and thoughts there.
For example, the M23 Code Set, Internal derangement of the knee, Excludes(1) currentinjury of the knee and lower leg (S80-S89). The M24 Code Set, Other specific joint derangements, which has some codes relevant to the knee, also Excludes(1) current injury of the knee ... as well. The S83 Code Set Excludes(1) the codes in M22, M23, and M24 code sets that apply to the knee and patella. Even more specific is that S83.2 pertaining to meniscal tears Excludes(1) M23.0, M23.2, and M23.3.
Unfortunately I don't know how to resolve these issues. I have some ideas, but not the clout nor the where-with-all to get changes made with CMS. For example, there is no need for both Code Sets M23.2 and M23.3. These could be simplified to one set for Old/Chronic and Other Meniscal Tears/Derangements, including degenerative, old traumatic, or "other," with 5th Characters of 1 through 6 as described already, and 6th Character for laterality. As for Chronic Instability of the Knee (M23.5), this could be
expanded to include from Old Ligamentous or Other Injury. This would allow for the expansion of the code set with 5th Characters for the different types of instability (anterior, posterior, medial, lateral, rotary, and multiple and/or complex ligament injuries, and their synonyms). This would be better than trying to get the knee (5th Character 6) included in M24.2 _, which has no room for this expansion.
I am sorry you are having to deal with Aetna. I am no expert on insurance companies, and have never liked of any of them, but by history and reputation in the Medical Provider realm, Aetna is the worst. They will bend, turn, twist every rule or interpretation they can their way so as to not pay for care. So what you tell me is no surprise. However, surgical treatment of a chronic meniscal tear (degenerative, old traumatic, or otherwise) is not "experimental" if the patient's clinical problem is well/clearly explained by the meniscal tear, and the indications for surgical treatment of the tear are documented, i.e. Medical Necessity is fulfilled. I wish I had some good advise as to how to deal with them.
I don't know if any or all this helps, but I agree and commiserate with you on these problems.

Sincerely, Alan Pechacek, M.D.
 
That helps a lot, sir. I can show this to the doctors on staff so they can understand the necessity for good documentation on clinical problems to prove medical necessity for stubborn payors like AETNA.

Peace
@_*
Thank you so much again.
 
daedolos said:
That helps a lot, sir. I can show this to the doctors on staff so they can understand the necessity for good documentation on clinical problems to prove medical necessity for stubborn payors like AETNA.

Peace
@_*
Thank you so much again.
Click to expand...

You are welcome. I certainly hope all of this helps you and others.

Alan Pechacek, M.D.
 
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