RMC’s AHIMA Approved ICD-10 Trainers meet multiple times per week fielding questions from clients and staff. Below is an actual question that was submitted, along with our team’s response.*
Doctors put very often “Degenerative changes are seen…” , on the XR, MRI, CT of hip, knee, shoulder, wrist, hand, foot, so on.
Do we code it as DJD of the pertaining site or use code for Other specified joint disorder of pertaining site/joint like M25.851?
RMC advice: It is not recommended to code to DJD because coding book index does not lead the coder there. For degenerative changes of joint (not of vertebrae or spine) use codes from category M24.8_.
**IF for joint- as per Index= begin search as “changes, joint” -> see derangement joint, specified type (meaning degenerative) then select appropriate body site (M24.8_)
**IF for spine or vertebrae- as per Index = degenerative, changes , only options are for spine and/or vertebrae (see spondylosis) spondylosis -> (M47.XX)
Index does not provide any direction for “changes” locations such as intervertebral disc. It is difficult to answer question without more documentation supported in question. (i.e. age of patient, reason for X-ray, other conditions etc.) Trainers caution to use entire chart for assigning codes. The difficulty lies to determine if “changes” are significant or are considered to be “normal” for patient’s age or other comorbidities.
Recommend referring to index for correct coding. There is no set answer for each scenario.
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* Every effort has been made to answer these questions to the best of RMC’s abilities, at the time the original question was submitted. Answers should not be considered official coding advice, and we always encourage conversation and dialogue regarding our responses. As best practice policy, always be sure to refer to your Official Coding Guidelines , Coding Clinic, CPT Assistant, etc.