RMC’s AHIMA Approved ICD-10 Trainers meet multiple times per week fielding questions from clients and staff. Above is an actual question that was submitted, along with our team’s response.*
I would like to get some clarification on “tear” codes. I code a lot of ortho charts with rotator cuff tears, SLAP tears, meniscus tears etc. To avoid second guessing myself most of the time I am coding diagnosis codes on them, I would like to know how you would code them when they are not traumatic tears which go to sprain. I know there are codes for rotator cuff tears not specified as traumatic, but what about a
- Degenerative SLAP tear
- Bicep tear
- What if the tear isn’t specified as neither traumatic or degenerative?
- The same with the meniscus tears, I know there is a code for traumatic and degenerative but what if no injury is specified?
- How far back should we go for an injury? Because it could be months that other measures are taken, like PT before surgery is then performed. Or do we code them as “old” after a certain time has passed which I believe goes to “derangement”?
- Degenerative SLAP tear Index- Degeneration, anterior labrum = S43.49–
- Bicep Tear- Index- tear/torn- muscle (and fascia) (and tendon)-> see strain- strain muscle, see injury muscle strain by site > Injury, muscle, bicep, strain = Category S46.21–
- If documentation doesn’t state traumatic or degenerative then a query to the provider might be needed. Coders need to follow the index and the way the code book leads us for proper coding. If the book doesn’t lead you to a default code, then you need to ask your facility for coding guidance, ie when to query.
- Index Tear or torn
meniscus (knee) (current injury) S83.20
(Knee) (Current Injury) are both non-essential modifiers, so acute (current Injury) S83.209, is the default when not specified.
5. “Old” is subjective and coders are not to interpret this based on any specific time frame or without specific documentation from the provider. A coder may not look back to previous encounters and should only assign codes from documentation of current encounter. “Tear or Torn meniscus” codes to current injury by default, category S83.2—. The appropriate 7th character will identify the stage of treatment.
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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.