Orthopedic Coding Alert

Question: Our orthopedist documented that a patient was suffering from pain, swelling, tenderness, and weakness in the hands. His notes indicate a diagnosis of myositis. When I went to the ICD-10 index, however, I found three potential codes: M60.14, M60.04, and M60.84. Which one should I code, and why?

West Virginia Subscriber

Answer: Unless the notes indicate that the cause of the myositis is bacterial in nature, you can immediately rule out M60.04- (Infective myositis, hand and fingers) in this situation.

Of the other two codes, M60.14- (Interstitial myositis, hand) is the more specific diagnosis of the two, suggestive of an autoimmune disease or an infection, whereas M60.84- (Other myositis, hand) is a more general inflammation affecting the connective tissues ofthe hand.

So, you would have to determine the exact code by digging deeper into the patient's notes. If the provider has recorded disease or infection, you would probably use M60.14-, but before you use any of these codes, you should consult with your practitioner. Also note that, in each case, you will need a sixth character to indicate which hand is involved; if both hands are afflicted, you will need a code for each hand.

Last resort: If you cannot glean any more information on the patient's condition, report the ICD-10 default code M60.9 (Myositis, unspecified) for the patient's condition.