Primary Care Coding Alert

Heads up: ICD-10 will include many more options in 2013.

A diagnosis of gout might seem simple enough to code, but a quick look at your ICD-9 choices shows more than 10 viable options. Ask your physician to provide details to help you pinpoint the correct code -- and to help prepare for ICD-10, when you'll have even more choices to consider.

Is It Joint Pain, Arthritis, or Gout?

Part of accurate coding includes understanding the conditions you're reporting.

"Gout is a form of arthritis of the joint that occurs due to high levels of uric acid in the blood," says Kristi Stumpf, MCS-P, CPC, COSC, ACS-OR, owner of Precision Coding and Auditing and senior coder and auditor for The Coding Network in Washington. "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."

Joints are a primary target site for uric acid crystal deposition. "When crystals form in the synovial fluid, it causes recurring attacks of joint inflammation, or arthritis," Stumpf explains. "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."

Diagnoses: Gout diagnoses fall under code family 274.xx (Gout) in ICD-9. For a patient's first experience with gout, 274.01 (Acute gouty arthopathy) might be your best choice, unless the physician doesn't specify a type of gout. In that instance, you should report 274.9 (Gout, unspecified).

Watch for Tophi and a Different Diagnosis

Some patients who have longstanding gout diagnoses might develop tophi. A tophus (the singular form of tophi) is a mass of uric acid crystals that often appear around joints. Less common locations for tophi can include the patient's cartilage, bone, synovium, skin, kidneys, or other organs. The deposits often signify chronic gout since they usually take about 10 years to develop after the onset of gout.

"Tophi are 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, a compliance and research specialist with Twin Cities Orthopedics, P.A.

Choices: Once the physician ascertains chronic gout, ICD-9 offers two diagnoses. Check whether documentation mentions tophi to determine whether to report 274.02 (Chronic gouty arthopathy without mention of tophus [tophi]) or 274.03 (Chronic gouty arthopathy with tophus [tophi]).

Look Ahead to ICD-10 Options

When ICD-10 goes into effect in October 2013, your diagnosis options for gout greatly expand.

Example: Whereas ICD-9 has a single code for chronic gout with tophi, ICD-10 will allow you to indicate chronic gout with tophi using any one of more than 100 codes. Under ICD-10, chronic gout is classified to a series of codes beginning with M1A. A fourth character further classifies the gout as follows:

• M1A.0 Idiopathic
• M1A.1 Lead-induced
• M1A.2 Drug-induced
• M1A.3 Chronic gout due to renal impairment
• M1A.40x1 Other secondary chronic gout
• M1A.9 Chronic gout, unspecified

Fifth and sixth characters can further specify location of the chronic gout. For example, M1A.011 indicates "Idiopathic chronic gout, right shoulder." To indicate with tophus (or tophi), simply append the seventh character of "1." A seventh character of "0" indicates "without tophus (tophi)." These seventh characters may be added to any code from category M1A. Thus, unspecified chronic gout with tophus (tophi) would be coded as M1A.9xx1.

Take note: Under ICD-10, information about the underlying cause and anatomic location are important to your coding. "For any of the ICD-10 codes for chronic gout with tophi, the presence of tophi would need to be supported by documentation, and the causative factor and location of gout would determine code selection," says Stumpf.