Orthopedic Coding Alert

One ICD-9 code expands to five ICD-10 codes.

When reporting gout as a cause of arthritis in 2013, you will need to look at the underlying cause of the gout, irrespective of the site involved, to pick up the right ICD-10 code. Here is how you will narrow down your choice from five available codes for chronic gout with tophi when the Oct. 1, 2013 deadline hits.

Gout, essentially a disorder of uric acid metabolism, can progress to a chronic condition that affects joints. Arthritis is a common manifestation of gout due to deposition of urate crystals in the joints which lead to inflammation. "Gout is a form of arthritis of the joint that occurs due to high levels of uric acid in the blood. Elevated uric acid levels associated with gout attacks causes uric acid crystals to deposit in the synovial fluid of the joints and other soft tissues," says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner, Precision Coding and Auditing, senior orthopedic coder & auditor, The Coding Network, Washington.

Joints are an important target site for uric acid crystal deposition. "When crystals form in the synovial fluid, it causes recurring attacks of joint inflammation (aka arthritis). Chronic gout can lead to deposits of hard lumps of uric acid in the tissues, called a tophus or tophi, in and around the joints that can lead to joint destruction," says Stumpf.

ICD-9: There is only one code for chronic gout with tophi in ICD-9. Code 274.03 (Chronic gouty arthropathy with tophus [tophi]) describes the joint involvement in chronic gout.

Learn More About Tophus

Tophus (tophi in pleural) is pathognomonic of gout. A tophus is essentially a deposit of monosodium urate crystals in people with longstanding high blood levels of uric acid. Tophi can form in the joints, cartilage, bone, synovium, skin, kidneys, and other organs in people suffering from gout. "Topi are nodular masses of uric acid crystals that commonly appear around joints," says Stumpf. Tophi, often signify chronic gout as these require an average of about ten years to develop after the onset of gout. However, tophi can appear as early as two or three years after gout onset and as late as even forty years after gout onset. These may form early in the elderly and affect both men and women. "More common in men than women, but the incidence in women increases after they reach menopause," says Ruby O'Brochta-Woodward, BSN, CPC, CCS-P, COSC, ACS-OR, compliance and research specialist, Twin Cities Orthopedics, P.A.

ICD-10 has five codes for chronic gout with tophi. These are enlisted below.

• M1A.00x1 Idiopathic chronic gout, unspecified site, with tophus (tophi)
• M1A.20x1 Drug-induced chronic gout, unspecified site, with tophus (tophi)
• M1A.30x1 Chronic gout due to renal impairment, unspecified site, with tophus (tophi)
• M1A.40x1 Other secondary chronic gout, unspecified site, with tophus (tophi)
• M1A.9xx1 Chronic gout, unspecified, with tophus (tophi)

Ignore The Site

If you look at the code descriptors above, you will see 'unspecified site' in all. The site of involvement in gout when accompanied by tophi, is not important in ICD-10 codes. If you have a patient who has joint pains and upon investigation tophi are confirmed in the lower extremity joints, you needn't bother which joint is involved. You confirm chronicity of gout due to presence of tophi and narrow down to your choice of codes for chronic gout. "For each of the five ICD codes for gout with tophi, the presence of tophi would need to be supported by documentation and the causative factor of gout would determine code selection," says Stumpf.

Look For The Underlying Cause

Gout is a metabolic disorder that has numerous causes. Make sure your surgeon documents the cause when doing any procedure to treat gouty arthritis with tophi. In a large number of cases, the cause may remain undetermined despite of extensive investigations. In such circumstances, you report M1A.00x1.

A possible cause of gout is renal impairment that causes uric acid to build up in the blood due to compromised excretion (M1A.30x1). Gout can also be caused due to use of drugs that cause hyperuricemia due to alteration of filteration, secretion, or reabsorption of uric acid.

Drug-induced gout (M1A.20x1) can be caused by long term use of drugs like thiazide uretics, furosemide, indapamide, amiloride, cyclosporine, cisplatin, salicylates, levodopa, etc. There are several conditions that increase the likelihood of gout (M1A.40x1). These include excessive consumption of alcohol, hypertension, diabetes, hyperlipidemia, and arteriosclerosis. "Gout can be inherited, or can be promoted by obesity, weight gain, alcohol intake, high blood pressure, abnormal kidney function and drugs," says Stumpf.

"In the presence of tophi and without location in the body being specified, you will report chronic gout with M1A.00x1 when there is a spontaneous onset of gout, with unknown cause; M1A.20x1 when the gout due to drug which must be specified by another code (T36-T50); M1A.30x1 when the cause is renal impairment; and M1A.40x1when the cause is something other than drugs or renal impairment; and M1A.9xx1when the gout is without a specified cause or location and there is no documentation of it having an spontaneous but unknown cause (idiopathic)," says O'Brochta-Woodward.

Note: M1A.9xx1 (Chronic gout, unspecified, with tophus [tophi]) is an unspecified code that you can use to report gout when the cause is either not ascertained or not available. "This is an unspecified code that would likely result from minimal documentation by the provider allowing a more specific code choice," says Stumpf. You will report M1A.9xx1 when there are tophi but the cause for chronic gout is unknown," says O'Brochta-Woodward.