Orthopedic Coding Alert

Question: An established patient suffering from acute osteomyelitis in his right shoulder reports to the orthopedist for a check-up on his condition. Notes indicate that the provider performed a problem focused history, an expanded problem-focused examination, and low-complexity medical decision making (MDM). What is the correct CPT^® and ICD-10 code for this condition?

Colorado Subscriber

Answer: First, we’ll dispense with the CPT^® code. You’ll report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity …) for the provider’s service.

As for the ICD-10 code, things are a little murkier. Your primary diagnosis will be one of two codes; go back and check the encounter notes, and then choose one of these diagnosis codes:

• M86.011 (Acute hematogenous osteomyelitis, right shoulder)
• M86.111 (Other acute osteomyelitis, right shoulder).

Secondary Dx alert: In the section devoted to osteomyelitis, ICD-10 instructs coders to use an additional code to identify the infectious agent underlying the condition. You’ll choose a code from one of the following code sets to ID the infectious agent:

• B95.- (Streptococcus, Staphylococcus, and Enterococcus as the cause of diseases classified elsewhere)
• B96.- (Other bacterial agents as the cause of diseases classified elsewhere)
• B97.- (Viral agents as the cause of diseases classified elsewhere).

Some of these codes require a fourth character, while others in the same family might require you to code to the fifth character. Keep this in mind as you sift through these secondary diagnoses.

Third Dx possible: Not only should you include an infectious agent code secondary to the osteomyelitis, you might need a third diagnosis to identify a major osseous defect, if applicable. In this patient’s case, you’ll choose M89.711 (Major osseous defect, right shoulder region) if the patient has a major osseous defect in addition to the acute osteomyelitis.