Pediatric Coding Alert

Time to make choosing the right M00-M99 code pain-free.

You know all too well that even the most straightforward of diagnoses can result in you having to choose between two or more different ICD-10 codes. And nowhere is that truer than when you have to code diagnoses relating to a patient’s musculoskeletal system.

So, to help take the guesswork out of finding the most specific code possible, here are three great questions you can ask yourself to help you code quickly and accurately.

Ask “Is This an Injury or not?”

It may seem obvious, but asking this one simple question will help you eliminate a lot of guesswork when your pediatrician’s diagnosis leads to two different possible ICD-10 codes.

Take this example. Your pediatrician documents that a patient had a charley-horse. When you look the condition up in the ICD-10 index, you see two different codes listed: M62.831 (Muscle spasm of calf) and S76.11- (Strain of quadriceps muscle, fascia and tendon).

To find the correct code in this case simply requires you “be aware that the S codes are injury codes that would be used following a specific injury that caused the strain,” says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico. “Knowing that charley-horses are generally not injuries would lead you to code M62.831, which is the first listed code in the index,” adds Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. This is confirmed in the index as the S76.11 code is preceded by the word “traumatic.”

So, providing your pediatrician has not indicated the condition was not caused by an injury, which seems most likely in this case, you would stay away from the injury codes and report a musculoskeletal code instead.

Ask “Where Is the Pain Located?”

Sometimes, your pediatrician is forced to provide a somewhat general diagnosis of pain. That can lead to further ambiguity among the codes. For example, foot pain can be coded as M25.57- (Pain in ankle and joints of foot) or M79.67- (Pain in foot and toes).

Which of the two do you use? The answer depends on the exact nature of that pain, and your knowledge of ICD-10 chapter divisions can help you narrow down the choice easily. “The M25 code is one of the arthropathy codes, which represent problems with the joints, while the M79 codes represent conditions involving the soft tissue,” Witt points out.

That means “if the pain is in the ankle or another joint within the foot, you would use M25.57- along with a sixth digit to specify which foot, and if the pain is in the soft tissue of the foot or toes, you would use M79.67- along with a sixth digit to specify laterality and whether the pain is in the foot or toes,” according to Moore.

Coding alert: As both codes are Excludes2 codes for each other, it is entirely possible that you could use both in this situation depending on your pediatrician’s documentation.

Ask “What Does This Term Mean?”

Very often, a basic knowledge of anatomic terms will enable you to make the correct choice between two similar-sounding conditions.

Take this last example. A pediatrician documents that a patient’s pelvis is contracted. Looking up Contraction, muscle, pelvic region in the ICD-10 index yields M62.45- (Contracture of muscle, thigh). But further down the index, you also find “Contraction, pelvis (acquired) (general),” which leads you to M95.5 (Acquired deformity of pelvis).

Here, the correct code choice depends on your knowing the difference between the terms “contraction” and “contracture.”

“A contracture is a permanent shortening of a muscle or tendon, or when you get a very tight muscle that deforms the position of the muscle/tendon and puts that body part into an awkward, mostly permanent, position. So, for example, if the fascia surrounding the muscles and tendons is thickened due to disease, burns, or inactivity, you would choose M62.45-,” Witt explains.

The descriptor to M95.5, on the other hand, tells you to use this code if the patient’s history reveals the condition is caused by an injury or a disease. “An acquired deformity refers to one that a patient has had for a very long time that has displaced the normal position of the pelvis and may be congenital,” Witt elaborates.

Final coding note: Whenever you use a code from Chapter 13, make sure you follow ICD-10 guidelines at the beginning of the chapter, which tell you to “use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition.”