Keep these coding tips in mind to improve medical record documentation

Over the past few months, we’ve shared coding tips for certain diseases in an effort to help you improve medical record documentation. Coding for musculoskeletal and connective tissues disease can be challenging —that’s why we’ve included some tips below for the most common musculoskeletal and connective tissue diseases. Musculoskeletal and connective tissue diseases are classified in codes 710-739 in the ICD-9-CM manual.

Lupus erythematosus — This is an autoimmune and chronic inflammatory disease that can affect many parts of the body, including skin, joints, kidneys, heart and lungs. The ICD-9-CM code for systemic lupus is 710.0. Watch for the message “use additional code,” which instructs providers to use an additional code to identify any manifestation.

Rheumatoid arthritis — Considered a chronic condition, rheumatoid arthritis may be ascertained by reading a patient’s past medical history or by checking a problem list. Remember that joint pain or a diagnosis of arthritis is not considered RA. According to the current American College of Rheumatology guidelines and clinical practice standards, patients with this condition require the initiation of disease-modifying anti-rheumatic drug therapy within three months of diagnosis. Accurate management and documentation are also important for HEDIS performance measurement purposes.. Chronic diseases, such as RA, which  are treated on an ongoing basis, may be coded and reported as many times as the patient is receiving treatment and care for the condition. The ICD-9-CM code for rheumatoid arthritis is 714.0. Watch for the message “use additional code,” which instructs providers to use an additional code to identify any manifestation.

Osteoarthritis — The most common type of arthritis, osteoarthritis is a chronic joint disorder characterized by degeneration of joint cartilage and the adjacent bone. It usually occurs in the hands, knees, hip and spine. OA is also referred to as degenerative joint disease, hypertrophic arthritis and degenerative arthritis. OA for most sites, excluding the spine, is assigned codes from category 715. Osteoarthritis of the spine is assigned to category 721. For category 715, the fourth digit identifies whether the OA is generalized or localized, and the fifth digit identifies the specific site involved.

• Generalized osteoarthritis affects many joints and is assigned ICD-9-CM code 715.0X. If it involves more than one site, but it’s not specified as generalized, use code 715.8X.
• Localized osteoarthritis affects the joints of one site and is further identified as either primary or secondary.
  • Primary — Generally occurs in individuals 55 or older and is associated with aging, affecting joints of one site with no known cause (idiopathic). In this instance, use code 715.1X.
    Secondary – Affects a joint of one site and has a specific cause, such as an injury, another disease process, inactivity or genetics. In this instance, use code 715.2X.
• Note: If the localized osteoarthritis isn’t specified as primary or secondary, use code 715.3X. If the osteoarthritis isn’t specified as generalized or localized, the appropriate code is 715.9X.

Sacroiliitis — This condition occurs when pain is caused by inflammation of the sacroiliac joint that attaches the sacrum to the pelvis. Sacroiliitis is often missed or inappropriately treated. Sacroiliitis can occur as a complication of infections in the heart, skin, joints or muscle. It also can follow a back injury. Many times, sacroiliac pain is mistaken for another cause of low back pain, such as a ruptured disk, collapsed vertebra, spinal stenosis or osteoarthritis of the joints in the spinal cord. Sacroiliitis may also be part of an inflammatory arthritic condition known as ankylosing spondylitis. For ankylosing spondylitis, the ICD-9-CM code is 720.0; for sacroiliitis, use the code 720.2.

Osteoporosis — The most common bone disease, osteoporosis falls into two categories, primary and secondary.

• There are three types of primary osteoporosis:
  • Postmenopausal — Caused by lack of estrogen; use code 733.01.
  • Senile — Results from an age-related calcium deficiency; use code 733.01.
  • Idiopathic — Typically occurs in young adults with no obvious reason for the weak bones; use code 733.02.
• Secondary osteoporosis is generally caused by certain medical conditions, hormonal disorders, disuse or is drug-induced. For disuse, the code is 733.03; for drug-induced, use code 733.09 and use an additional ‘E’ code to identify the drug. Refer to the Official ICD-9-CM Guidelines for coding and reporting.

For more information, please contact your provider consultant.