“Clean Up” Diagnosis Coding for Staged Revisions

“Clean Up” Diagnosis Coding for Staged Revisions – July 2015
by Margaret M. Maley, BSN, MS

Assigning diagnosis codes for joint revision surgery is challenging in both ICD-9-CM and ICD-10-CM. Orthopaedic practices that carefully examine the instructions in both editions may find that they have been reporting staged revisions incorrectly for years. The following side-by-side comparison of ICD-9 and ICD-10 coding will help clean up diagnosis coding for staged revision surgeries.

Let’s start with the diagnosis coding for the initial surgery—a right total knee replacement for primary osteoarthritis. In ICD-9-CM, the diagnosis code is 715.16 (osteoarthrosis, localized, primary, lower leg). In ICD-10-CM, the code is M17.11 (unilateral primary osteoarthritis, right knee). Although both ICD-9 and ICD-10 require that the etiology of the osteoarthritis (primary) be documented, ICD-10 also requires that laterality (right knee) be specified.

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