Wiki Tears: S Codes vs M Codes

[KStaten]

Greetings Fellow Coders,

Since I began coding, I have been hearing mixed opinions about what qualifies the diagnosis of a tear to become coded as an S code or an M code. At first glance, it seems as though it should be straightforward; however, explanations sometime fall into gray areas, as even expert opinions do not always coincide. I have listed a couple examples below. Your input would be greatly appreciated!

Example #1: A patient presents with pain in his left knee, which has been ongoing for years. He denies an injury. The MRI report shows a complex tear in the medial meniscus.

Example #2: A patient presents with pain in her right shoulder, which has been ongoing for years. She denies an injury. The MRI report shows a labrum tear.

Thanks!

 

[wisibyusha]

The guideline states: 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.
Having this in mind, I believe both your example fall in the chronic/recurrent section and hence, it will be in chapter 13 or M code.

 

[KStaten]

The guideline states: 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.
Having this in mind, I believe both your example fall in the chronic/recurrent section and hence, it will be in chapter 13 or M code.

Thank you very much for your detailed response! I have seen mixed opinions about this so often. Some argue that if the report states "complex tear," (as in Example #1) then you must use the complex tear code S83.232A, regardless. In regards to Example #2, I have heard some argue that all labral tears are coded as S codes, while others suggest to use the "other articular cartilage disorders," (in this case, right shoulder, M24.111) for chronic or degenerative tears. I've used the latter, but still have issues with placing the labrum into the category of "articular cartilage," as it is a fibrocartilage, which, by nature, is distinctly different from articular cartilage. Oh the joys of coding!

 

[wisibyusha]

I am really amazed because people say that coders are thinkers! It is true. I read your feedback and I agreed about the "complex tear" since the guideline states "many" not all, and this opens the way for complex tear to fall under the S code. For the labral tear, I understand your concern about the definition of the structure which made me accept that coders are thinkers. So, check this code S43.43 and let me know what you think of it. when I was searching about the labral tear, the cause can be either injury or due to age process and on your example it states that the patient denies any injuries. But is it possible that it can fall in the S codes like example#1? Also, check the definition for labrum lesion.

 

[SavCoder]

When I attended the GAOE Orthopedic coding conference, this question was asked and this is what the speaker told us.

If there is no reference to degenerative/fraying/chronic/old tear and the documentation just states (for example) posterior horn meniscal tear, you are to query the provider. Coders should not assume. If you cant get an answer from the provider you are to use the ICD-10 guidelines section I - 1.A.18 - Default Codes.
"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."

Look for the following words in the medical record:
Degenerative, spontaneous rupture, recurrent, chronic, old, fraying = “Mxx.xxxx”
Traumatic, new, recent, traumatic rupture, acute = “Sxx.xxxx”

So if you look in the index for posterior horn medical meniscus tear, Tear > meniscus > medial > specified type > S83.24--. The default dx would be an "S" code.
But if you look up complete rotator cuff tear, Tear > rotator cuff > complete > M75.12--. The default dx would be an "M" code.

I find determining whether to use "M" vs "S" dx code confusing and frustrating at times. I wish AMA would come up with a solid guideline when determining "M" vs "S" dx code like they did for acute vs chronic - if not documented acute vs chronic the default is acute.