Wiki SI Joint Injection dx code M46.1 vs M53.3

medlcg79

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I sent the following email to my providers and received one positive response and one negative response and one non response. Reaching out to get your thoughts on it.

"Good afternoon,

I wanted to go over these diagnoses with you.

M53.3 Sacrococcygeal disorders, not elsewhere classified
M46.1 Sacroiliitis, not elsewhere classified

From the documentation on the Procedure note, it would seem that M46.1 would be the most appropriate code based on the Pre-Operative Diagnosis section stating "Sacroiliitis".

Also, the code does not need to be listed twice. I have to delete one of them on the claim because it creates an error. The codes themselves do not contain laterality. I've typed them above as they are listed in the ICD-10-CM book.

Please let me know what you think."

Negative Response:
"Hi everyone

I believe M53.3 (sacroiliac joint pain/disorder) is the correct icd 10 code, as this is the clinical diagnosis and syndrome we are treating with the joint injections
M46.1 - Sacroiliitis is a radiographic diagnosis identifying inflammation in the sacroiliac joints on imaging. If there is no imaging (CT or MRI) demonstrating inflammation in the joints, then this diagnosis is not appropriate. A patient can have sacroiliac joint pain (a clinical diagnosis) appropriately treated with a sacroiliac joint injection, without active sacroiliitis (M46.1)

Interested in hearing other thoughts/perspectives"

I reviewed his response last night and came across a website (https://my.clevelandclinic.org/health/diseases/17736-sacroiliitis) that indicates sacroiliitis is not just a radiographic diagnosis. Sacroiliac and Sacrococcygeal are two different structures.

Also, I'm not sure who put the dx codes in the system for them, but they do not match the description in our books.
 

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Well, the diagnosis is what the provider says it is. What code should be assigned is a different question. I think it's very important to keep these two questions separate. It's not up to the coder to tell the provider what diagnosis should be, only to educate them if they select the incorrect code to represent their diagnosis.

I think it's fine that you've asked the provider not to repeat the code twice since you have to delete it. It think it's also fine to tell the providers the coding rule that you don't need to code the symptom if there is a definitive diagnosis, which is perhaps what you're trying to say here?

In the 'negative response' you've quoted here (which actually doesn't really sound that negative to me though), the provider is clearly telling you that in their opinion this patient does not have sacroilitis. But if you're going to challenge a physician about whether or not the patient should be diagnosed as having sacroilitis, or question their statement that it's a 'radiographic diagnosis', whatever that might mean, I think that you're acting outside the scope of coding. In my experience, it's not a good idea get into that area as providers can interpret this to mean that you're telling them how to practice and it can negatively impact your working relationship with them, so I would just let it be. And it's perfect fine if one physician has a one idea about when to give a patient a particular diagnosis and other physicians don't necessarily agree. But as a coder, we should just assign the code that best represents each physician's diagnosis as they've documented it, and leave it at that.

Hope that might help some.
 
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Well, the diagnosis is what the provider says it is. What code should be assigned is a different question. I think it's very important to keep these two questions separate. It's not up to the coder to tell the provider what diagnosis should be, only to educate them if they select the incorrect code to represent their diagnosis. It's not surprising to me that you'd receive a 'negative response' to an email like this because, whether intended or not, it does come across a bit like you're telling the providers what diagnosis they should be giving their patient.

In the 'negative response' you've quoted here (which actually doesn't really sound that negative to me though), the provider is clearly telling you that in their opinion this patient does not have sacroilitis. It may have been the pre-operative diagnosis, but if there final assessment after the procedure is that this diagnosis was not present, then it shouldn't be coded. And it's perfectly appropriate to query the provider for clarification if it's not clear from the documentation if that condition was present or not. But if you're going to challenge a physician about whether or not the patient should be diagnosed as having sacroilitis, or question their statement that it's a 'radiographic diagnosis', whatever that might mean, I think that you're acting outside the scope of coding. In my experience, it's not a good idea get into that area as providers can interpret this to mean that you're telling them how to practice and it can negatively impact your working relationship with them, so I would just let it be. And it's perfect fine if one physician has a one idea about when to give a patient a particular diagnosis and other physicians don't necessarily agree. But as a coder, we should just assign the code that best represents each physician's diagnosis as they've documented it, and leave it at that.

Hope that might help some.
I agree with you. What I was informing them is that the documentation on the report does not support the diagnosis that was chosen. I thought I was clear about that in my email to them. They can use the dx code they deem appropriate, but the documentation needs to match. I wanted input so that I can learn and help guide my response because I don't believe they understood what I was trying to convey. Thanks for your input.

As far as the "negative response" I had used positive response for the agreeable one and therefore used "negative" for the non agreeable one. I'll choose better descriptors in the future.
 
I agree with you. What I was informing them is that the documentation on the report does not support the diagnosis that was chosen. I thought I was clear about that in my email to them. They can use the dx code they deem appropriate, but the documentation needs to match. I wanted input so that I can learn and help guide my response because I don't believe they understood what I was trying to convey. Thanks for your input.

As far as the "negative response" I had used positive response for the agreeable one and therefore used "negative" for the non agreeable one. I'll choose better descriptors in the future.
Yes, I see that I was still editing my post when you responded, sorry about that, I had posted too quickly without reviewing everything - please see my updated post. I hope that my own response didn't come across as too negative as a result!

I agree with you that the documentation and then their response to your email is confusing and what the physician has said does match what he or she documented. If the physician doesn't think the patient has sacroilitis, then they shouldn't have documented 'same' as the post-operative diagnosis.

It's definitively a challenging thing when physicians are both coding and diagnosing at the same time. They don't understand the distinction and just want to select the code that has a descriptor they think most closely matches the diagnosis they want to use, and it can lead to a lot of problems. When possible, it's best if they can just document conditions and not get into code selection at all, but I know that's not always an option in all practices.
 
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Yes, I see that I was still editing my post when you responded, sorry about that, I had posted too quickly without reviewing everything - please see my updated post. I hope that my own response didn't come across as too negative as a result!

I agree with you that the documentation and then their response to your email is confusing and what the physician has said does match what he or she documented. If the physician doesn't think the patient has sacroilitis, then they shouldn't have documented 'same' as the post-operative diagnosis.

It's definitively a challenging thing when physicians are both coding and diagnosing at the same time. They don't understand the distinction and just want to select the code that has a descriptor they think most closely matches the diagnosis they want to use, and it can lead to a lot of problems. When possible, it's best if they can just document conditions and not get into code selection at all, but I know that's not always an option in all practices.
Just wanted to give you an update. I emailed them back and informed them that I was not trying to tell them how to diagnose the patient. I was just trying to convey that the documentation did not match the diagnosis selected. Suggested they replace "Sacroiliitis" with something else if M53.3 was truly what they wanted to use since the dx code for sacroiliitis is M46.1. I have not gotten a response yet, but I have noticed a change on today's SI Joint injection reports. They now have "Sacroiliac Joint Pain" instead of "Sacroiliitis".

Thanks again for your input
 
Other things to consider with additional conditions that fall under M46.1 from AHA Coding Clinic and from standpoint of how the ICD-10 committee acknowledges the limited code set for sacroiliac condtions. ICD-10 code M53.3 does not have any AHA Coding Clinic References.

AHA Coding Clinic Second Quarter 2020

AHA: 2020, 2Q, 14 ICD-10 M46.1

DEF:
Inflammation of the sacroiliac joint (situated at the juncture of the sacrum and hip). Symptoms include pain in the buttocks or lower back that can extend down one or both legs.

Degenerative Joint Disease of Sacroiliac Joint

Question:


A patient is diagnosed with bilateral lower sacroiliac degenerative joint disease (DJD). When referencing the Index to Diseases under Degenerative, joint disease, ICD-10-CM directs the coding professional to see “Osteoarthritis.” However, the Index to Diseases does not specifically classify osteoarthritis (OA) of the sacroiliac joint. What is the appropriate code assignment for bilateral lower sacroiliac degenerative joint disease (DJD)?

Answer:

Assign code M46.1, Sacroiliitis, not elsewhere classified. DJD of the sacroiliac joint is caused by degeneration, leading to inflammation of the sacroiliac joint. Currently, the ICD-10-CM does not have a unique code for DJD of the sacroiliac joint; therefore, code M46.1 is the closest available alternative. The National Centers for Health Statistics has agreed to consider a future ICD-10 Coordination and Maintenance (C&M) proposal for creation of a new code for DJD/osteoarthritis of the sacroiliac joint.


New codes contained in this issue effective with discharges April 1, 2020. Other coding advice or code assignments contained in this issue effective May 29, 2020.
 
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