Podiatry Coding & Billing Alert

Differentiating acute, chronic will be key in identifying the right code.

When your podiatrist sees a gout patient, your diagnosis coding choices aren’t as straightforward as you might think.

Why? Because there are multiple types of gout, the condition can be primary or secondary. And it’s often classified as acute or chronic. Because of this, navigating the coding options can result in complete confusion.

To ensure that you select the most accurate gout code every time, start by opening your ICD-10-CM code book to the “M” section and read on for the rest of the scoop.

Know the Gout Types

The first step in identifying the right gout code involves understanding the terminology that providers and ICD-10-CM use to describe the condition. Check out the key terms you’ll need to know as you navigate the diagnosis code options:

Gout: Caused by deposits of monosodium urate crystals in the joint. Report idiopathic chronic gout (chronic gout that has no known cause) with a code from the M1A.0- (Idiopathic chronic gout) series.

Pseudogout (also referred to as Chondrocalcinosis): Caused by calcium pyrophosphate crystal deposits in the joint, you would report this with a code from M11.2- (Other chondrocalcinosis) group.

Gouty arthropathy: Caused by urate crystal deposits in the joints and other organs. Without a more specific diagnosis, you might consider reporting M11.9 (Crystal arthropathy, unspecified) for this condition.

Coding caution: One problem facing coders involves providers using numerous terms that describe similar, yet slightly different, conditions. “It is very common for providers to state gouty arthropathy, gouty arthritis, or pseudogout,” says Ruby O’Brochta- Woodward, BSN, CPC, CPMA, CPB, COSC, CSFAC, coding and compliance manager at Suburban Imaging in Minneapolis.

If you can’t tell which of these definitions describe your patient’s condition after reviewing the documentation, you should query the podiatrist to find out which type of gout to start with. Once you’re aware of the gout type, you can move on to the next steps in coding the condition.

Pinpoint Acute vs. Chronic Gout

Once you know the type of gout your patient has, you’ll need to identify whether it’s acute or chronic before you can pinpoint a specific ICD-10-CM code. To do this, you may need to consult the definitions of each, since the podiatrist may not use the terms “acute” and “chronic” in the documentation.

Acute gout: When the patient is showing the initial, early clinical manifestations of gout, characterized by severe joint pain and swelling, this may indicate acute gout, which you’ll code using the M10- (Gout) series.

Chronic gout: When the patient’s gout recurs and/or involves multiple joints, that may indicate chronic gout, which is coded from the M1A- (Chronic gout) range.

Remember: There is no guideline in ICD-10-CM that defines a condition as acute or chronic based on a timeframe. Guideline B.8 (Acute and Chronic Conditions) only tells you to code the acute (or subacute) condition first in a situation where a condition is described as both acute (or subacute) and chronic and there are codes for both “at the same indentation level.”

You also cannot look for guidance from professional organization to determine whether a condition is acute or chronic, as they use different timeframes for chronic conditions. The National Cancer Institute, for example, defines a chronic disease as “a disease or condition that usually lasts for 3 months or longer” (Source: www.cancer.gov/publications/dictionaries/cancer-terms/ def/chronic-disease), while the Centers for Disease Control and Prevention (CDC) defines chronic diseases “conditions that last 1 year or more” (Source: www.cdc.gov/chronicdisease/about/index. htm). As there is such a huge discrepancy in the definitions used by professional institutions, it seems clear that you cannot use any one specific time period to determine when acute conditions end and chronic conditions begin.

This means the decision to define a condition as acute or chronic is up to your provider, and your coding needs to be dependent on their judgement. If you are habitually confused about whether to use an acute or chronic gout code, it may be a good idea to ask your podiatrist to denote acute and chronic in their documentation in the future.

Look for Mentions of Tophi

If your documentation review indicates that the patient has chronic gout, you’ll then need to investigate the medical record further to determine whether the patient has signs of tophi, which will help you determine the diagnosis code’s 7th character.

First, however, you’ll need to know what tophi (or tophus) refers to. Tophi “are deposits of urate crystals in the joints. The body can’t get rid of the amount of urates produced over time, which leads to crystal formation,” explains Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

As “there has not been enough time for this to happen in the acute state, tophi usually only appear with a patient with chronic gouty arthritis,” Witt notes. This is why you’ll only see “with tophi” added to code descriptors in the M1A- series.

For example: To document drug-induced chronic gout in the patient’s left ankle and foot with tophi, you would report M1A.2721 (Drug-induced chronic gout, left ankle and foot, with tophus (tophi)).

If, however, the patient had no tophi, you’d report M1A.2720 (Drug-induced chronic gout, left ankle and foot, without tophus (tophi)) instead for drug-induced chronic gout in the patient’s left ankle and foot.

Secondary Gout Is Caused by Another Factor

When you’re perusing the gout codes, you’ll notice that some codes are marked as “idiopathic” or “primary” and some designate secondary gout, or gout that has been caused by a medication or another medical condition. The cause is denoted using the 4th character of the ICD-10-CM code, as follows:

• M10.1/M1A.1 (Lead-induced …)
• M10.2/M1A.2 (Drug-induced …)
• M10.3/M1A.3 (… due to renal impairment)
• M10.4/M1A.4 (Other secondary …)

When you’re reporting a secondary gout code, you’ll note that ICD-10-CM advises you to “Code first associated condition.” In other words, the primary condition should be coded first, followed by the gout code.

For instance: Suppose your podiatrist sees a patient who has chronic gout without tophi in the right ankle and foot due to arthropathic psoriasis. In this situation, you would report L40.5- (Arthropathic psoriasis) first, followed by M1A.4710 (Other secondary chronic gout, right ankle and foot, without tophus (tophi)).

Look to 5th and 6th Characters to Describe Location, Laterality

When you’re choosing your gout code, you’ll notice that you can’t typically designate the affected location until you get to the code’s fifth character. Because most podiatrists are