Update to coding “degenerative changes”

Guest blog by Monita Turpin, coding analyst at 3M Health Information Systems.

In my last blog, I wrote about the conundrum of assigning ICD-10-CM code when providers only document “degenerative changes.”

I wrote my blog in early June 2018. The day before my blog was published, I received notification of an updated Coding Clinic, Second Quarter ICD-10 2018 Page: 15 Effective with discharges: June 6, 2018. 

So, let’s revisit the scenario with the clarification from Coding Clinic:

The provider documented “degenerative changes of the left knee” in the impression, and the clinical indication was left knee pain. What is the correct diagnosis code?

The question that was submitted to Coding Clinic was:

What is the correct code assignment for advanced degenerative changes of both hips when documented in the final impression section of an outpatient radiology report?

According to Coding Clinic: “Assign code M16.0---Bilateral primary osteoarthritis of hip for degenerative changes of hips”. 

Coding Clinic’s rationale is, “ICD-10- CM's Alphabetic Index under "Degeneration, joint disease" instructs "see Osteoarthritis."

This is a major change that some will say has not completely colored in the grey area for “degenerative changes” because the provider did not specify “joint disease;” however, we must code based upon guidelines and when guidelines are not clear, we must go to Coding Clinic for guidance.

Monita Turpin is a coding analyst at 3M Health Information Systems.