Wiki diagnosis for osteoarthritis

[Ash82]

When coding osteoarthritis, does the physician have to actually say primary osteoarthritis in order to assign that code? I think we can assume that most patient's oa, especially elderly patients, arthritis is due to normal the normal aging process and not due to a trauma or secondary but I have always been taught you never assume. So if the patient has primary oa but the physician doesn't state that it's primary, do you have to use the unspecified codes, such as M17.9 for knee, M16.9 for hip, M19.90, etc.....?

 

[mitchellde]

No you cannot assume. Even an elderly persons osteoarthritis could be due to a trauma from when they were younger. If the provider documents age related or no known cause or due to wearing out or over use you may code as primary.

 

[Ash82]

So, if the physician does not document that it is due to age, trauma, no known cause, etc.... you must use the unspecified, correct? Does that apply to all joints? The knee, hip and first metacarpal joint are the only ones with unspecified code. If the physician basically never documents the cause of the arthritis, do you have to code as unspecified each time?