1 Codingline Particulars Plantar Plate repair , Coding sequela , and Other Topics Here are the answers to some commonly-asked questions. By Harry Goldsmith, DPM. Welcome to Codingline Partic- a 7th character (A, D, S) Disorder of ligament, left foot . ulars, a regular feature in Podiatry Sprain of metatarsophalangeal 49. management focusing on foot and joint of left lesser toe: plus a ankle Coding , billing, and practice 7th character (A, D, S) With the M ICD-10 codes, if management issues. there are symptoms present with the These code choices presume in- deformity(ies) add the appropriate Plantar Plate repair jury, such as laceration or traumatic symptom ICD-10 code. For example: tear of cartilage, joint, or ligament of Pain in right foot What would be the best diag- metatarsophalangeal joint. Pain in left foot nosis code to use for a Plantar Plate tear?
2 And what would be the CPT. code for a primary repair of a Plantar Plate tear? There is no specific CPT or ICD-10 code for a Plantar Plate tear. There is no specific CPT or ICD- 10 code for a Plantar Plate tear. If the procedure you perform was designed to repair the position and instability If the etiology is a spontaneous Pain in right toe(s) of the toe with repair of the metatar- rupture of the Plantar Plate , consider Pain in left toe(s) sal-phalangeal joint capsule/ligament using: (one would presume that is why you Other articular cartilage disor- sequela are there), then CPT 28313 (recon- ders, right foot Actually, Coding sequela in struction, angular deformity of toe, Other articular cartilage disor- ICD-10 is not all that difficult. There soft tissue procedures only) is appro- ders, left foot are, however, two issues that seem priate.
3 To always come up when discuss- ICD-10 Coding isn't quite as easy. Note: When there is no option of ing sequela 7th character use. First, The code you choose will depend on toe ICD-10 codes in a subcategory how deep into my history-taking your diagnosis (based on finding pre- that lists ankle and foot, foot codes do I need to go in order to determine and intra-op) and the etiology. Some would include toe diagnoses/condi- that the presenting complaint is the likely Coding candidates include: tions. result of an old injury?; and second, Sprain of metatarsophalangeal why bother [specifically in the cod- joint of right great toe: plus a If the finding is instability of the ing]? Those are very common and 7th character (A, D, S) joint or ligamentous laxity second- fair questions to ask. When a patient Sprain of metatarsophalangeal ary to a traumatic or spontaneous presents with pain in the left ankle, joint of left great toe: plus a rupture of the Plantar Plate , consider the typical history of present illness 7th character (A, D, S) adding: (HPI) questions (location, quality, Sprain of metatarsophalangeal Disorder of ligament, right foot severity, duration, timing, context, joint of right lesser toe: plus Continued on page 50.)
4 APRIL/MAY 2016 | PODIATRY management . Codingline Particulars Plantar Plate (from page 49) the diagnosis. If, after examining the patient four years previously had patient and reviewing x-rays, you are fractured the same ankle, and com- modifying factors, and associated able to make the diagnosis of degen- fortably tie that to the reason the pa- signs and symptoms) do not neces- erative joint disease, left ankle, you tient is in your office (osteoarthritic sarily lend themselves to capturing now have to whittle down the Coding changes to the left ankle, post-trau- information regarding a previous from these options: matic), you have the second diagno- injury to the same site. The closest (arthritis [juvenile sis the old injury. Obviously, you HPI element would be context (ex- rheumatoid arthritis], unspecified, will need to know either from infor- ample: tripped stepping off a curb).
5 Ankle and foot) mation relayed to you by the patient The problem is that most patients, (arthritis [neuropath- or from old records what the specif- when asked about any injury, have ic], ankle and foot) ic diagnosis of the time was ( , problems recalling specifics unless (arthritis [post-trau- lateral non-displaced closed fracture of the distal fibula, left) in order to accurately code it. In this case, the old diagnosis was (which Coding sequela is a two-step process. requires a 7th character). You are given 16 7th character options, but the only one you are interested in is the injury was recent. Most doctors matic], ankle and foot) S ( sequela ). Code it And aren't just satisfied with when the (arthritis [rheuma- you have your second code. latest bout of pain began, and do try toid], ankle and foot) Your billing would be: to elicit information on any possible (arthritis, due to Other (post-traumatic osteoar- injury.)
6 Unfortunately, some patients bacterial infection, ankle and foot) thritis, left ankle and foot). 50 fail to connect the dots regarding (arthritis, due to Pneu- (lateral non-displaced their present complaint and an old mococcal infection, ankle and foot) closed fracture of the distal fibula, injury; some patients forget the orig- (arthritis, due to Reit- left; sequela ). inal injury (if it occurred months or er's disease, ankle and foot). years ago) and instead dwell on the (arthritis, due to Staph- Begging the questions: episodes of pain or limitations. ylococcal infection, ankle and foot). So, that brings up a question fre- (arthritis, due to Strep- 1) Won't I get paid if I just list quently asked when discussing se- tococcal infection, ankle and foot) on the claim? quela, and that is, to what level of (arthritis, localized, Response: Probably.
7 The point, detail am I obligated to press the pa- secondary, ankle and foot). however, is that like in your medi- tient in order to get historical details cal record documentation, you are and be able to correctly code for a sequela ? Since sequela Coding only pertains to current latent symptoms and/or limitations due to a previ- When you see a hyphen (-) at the end of an ICD-10. ous injury or illness (NOTE: surgical code, it indicates that you need additional characters to complications are not coded under sequela ), if the patient is unaware complete the code and make it a valid code. of the injury details necessary to correctly code ( , lateral non-dis- placed closed fracture of the distal A couple of probing questions expected to be as specific as you rea- fibula), do I need to request old re- ( , did you ever injure that ankle?
8 Sonably can in your diagnosis Coding . cords in order to accurately bill? The See Step #2 below) should get you Specificity in your service and proce- answer is, I don't know. I would down to the most likely diagnosis dure Coding goes without question. say that if the information is readily which will be then be your primary available, you should use it to code diagnosis. Only code the presenting 2) What's with the hyphen the sequela . And I'll leave it at that. symptom ( , pain) if you cannot (dash) at the end of a code? make a specific diagnosis. Response: When you see a hy- So, how do you code a sequela ? Step #2: If you can discern the phen (-) at the end of an ICD-10. cause/etiology of the complaint (pri- code, it indicates that you need ad- Coding sequela is easy. It is a mary diagnosis), you code it sec- ditional characters to complete the two-step process.
9 Step #1: The first ond. For example, in the case of the code and make it a valid code. code (primary code) is the reason patient with the painful left ankle the patient made the appointment. In that you diagnose as arthritic chang- 3) I can't help but notice the Other words, take the chief complaint es (degenerative joint disease, os- lower case x in Why is it ( , my left ankle is painful), ex- teoarthritis), if in the course of your in lower case? amine the patient, and come up with history-taking, you find out that the Continued on page 51. APRIL/MAY 2016 | PODIATRY management Codingline Particulars Plantar Plate (from page 50) tis, left ankle and foot)? Would I still DISCLAIMER: The information be paid? offered by CodinglinePARTICULARS is Response: The base code is Response: Probably, but that's provided in good faith for purposes of with indicator noting that it not the point.
10 If the accurate diagno- communication and discussion, and is needs a 7th character. There is no sis is arthritis, localized secondary, strictly the opinion of the editor, Harry listed 6th character, just that to be a left ankle, then that's the diagnosis Goldsmith, DPM, or the listed authors. valid code there needs to be 7 char- you document in the medical record Neither Codingline nor Podiatry Manage- acters. To fill in the missing character and list on your claim form. ment represents that any such opinion is (we know what the 7th character either accurate or complete, and should will be an S , but there is no 6th 5) If I didn't see in a past record not be relied upon as such. The reader character option), we use the x whether the fracture of the lateral is responsible for ensuring correct appli- in the 6th character position to give malleolus was open or closed, or dis- cability of any information, opinion, or us Then x represents a placed or non-displaced, what am I statements written in by CodinglinePAR- placeholder (AKA dummy place- supposed to do?