Wiki Traumatic vs. Derangement

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Bridgetln

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There has been some debate on determining whether a case is traumatic vs. derangement. I would like some outside opinions on this topic in general and the specific case specified below.

Case # 1
SUBJECTIVE: **** is here today for evaluation of her left knee. *** has had left knee pain ever since mid-December. Prior to that she did not have any significant pain or problems and was able to ambulate without much difficulty. Now she has snapping, popping and significant pain to the lateral and posterolateral aspects of the knee, near locking episodes and the knee is unsteady for her although there is no gross instability complaints.

PLAN: At this time she does have some early degenerative changes as well as a lateral meniscal tear. However, I think she has lived with the degenerative changes for quite some time and the new onset of the lateral meniscal tear is quite symptomatic. Therefore, we have talked with her about treatment options. We have gone over the risks, complications, as well as benefits and expectations of surgery, postop protocol and follow-up. We will get this set up as soon as possible. Will get her medically cleared and I'll see her back at the time of surgery. Until then, she will continue with ice, elevation, modification of activities, etc.
 
This would be non-traumatic

This would be non-traumatic. At least there is no indication of injury or something like that.

Without an injury, I would code it as degenerative or derangement.
 
I agree with Orthocoderpgu. There's no indication of an injury or trauma so I would code your scenario as degenerative.

ICD-10-CM coding

In ICD-10-CM, coders will be working in two different chapters for orthopedic diagnoses. Chapter 13 is going to include all of the diseases of the musculoskeletal system and connective tissue. These codes begin with the letter M. These tend to be chronic and recurrent conditions, Pollard says.

Codes for acute injuries appear in chapter 19. For orthopedic injuries, the codes begin with the letter S. The S codes are injuries classified by site and then by type, and represent acute conditions and traumatic injuries.
ICD-10-CM introduces several new concepts for coding and some of these apply to coding for meniscus tears. One change involves looking at past medical records to determine whether an injury is acute or chronic.

Coders need to be careful about looking back in the patient’s medical record and bringing information forward. If the patient has a recurring injury, the physician must still document it on the current admission or encounter, says Gretchen Young-Charles, RHIA, senior coding consultant for the American Hospital Association in Chicago.

If the physician does not document whether the condition is acute, chronic, or recurrent, coders should use the 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, Young-Charles says.

The physician, especially on an outpatient record, is not always giving providing that full documentation of whether the injury is acute or chronic, Pollard says. “We really need to have the documentation to back up that we have an old tear. Otherwise, we have to go with our default code.”

In ICD-10-CM, meniscus tears default to acute.

When coders look in the ICD-10-CM Alphabetic Index under "tear, meniscus," they are directed to an S code, Stanton says. Codes for acute tears include:
Bucket-handle, S83.21-
Complex, S83.23-
Peripheral, S83.22-
Specified type NEC, S83.24-

The dash indicates that additional characters are needed to complete the code, Young-Charles says. In the case of meniscus tears, the codes further specify laterality and encounter, two details not required in ICD-9-CM.
For an initial encounter for a current peripheral tear of the medical meniscus of the left knee, coders would report S83.222A.

If coders are reporting an old tear, they are directed to “see Derangement, knee, meniscus, due to old tear.” These codes specify the portion of the meniscus that is torn, Pollard says. They also specify laterality, but not the encounter.

Old tears (M23.2-) are divided into one series for lateral tears and another for medial tears. The codes further specify the location of the tear:
Anterior horn (M23.21-, M23.24-)
Posterior horn (M23.22-, M23.25-)
Specified NEC (M23.23-, M23.26-)

For example, a patient comes in with a derangement of the posterior horn of the medial meniscus of the right knee due to an old injury. Coders would report M23.211.

http://blr.hcpro.com/content.cfm?content_id=314158
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I have a question on this subject.
I have a 1 year old ACL and Lateral meniscus tear and all that was done to treat this was bracing and physical therapy. This was due to the fact that the PT was not at skeletal maturity, per the Doctor. My doc is now treating this with an arthroscopic ACL and Meniscus repair. My question is, am I still supposed to code this as an S code with A as my 7th character in this case, or because of the timing of the injury, is this going to fall under the M coding set for these tears?
 
If the ACL and meniscus tears are traumatic, and the ACL is almost always traumatic, then you would use the S with an A at the end since "difinitive" treatment is still being performed. After the surgery the A would switch to D. There is no set time limit for definitive treatment.
 
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