ICD 10: Aftercare Z Codes or 7th Character Code?

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UPDATED

February 4, 2016

Question:
Patient has been seen in office during the global period after a rotator cuff repair for a sprain. No X-rays were taken. Internally we will record 99024. Would we assign Z47.89 or the sprain code to 99024?

Answer:
Thanks for your inquiry as your question gives us an opportunity to address documentation requirements and how sprains and strains are delineated in ICD-10-CM.

First, under ICD-10-CM descriptions, an acute injury to the rotator cuff muscle or tendon is described as a “strain”, under the subcategory S46,01- , not as a “sprain.”  Although there is also an ICD code for sprain of the rotator cuff capsule, S43.42-, that is not the structure that typically injured.

If you’ve determined that the problem is an injury, you will look to the S codes; if it is a chronic or recurrent problem, you will look to the M codes.

The ICD-10-CM options for a rotator cuff strain are:
S46.011- Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder
S46.012- Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder
S46.019- Strain of muscle(s) and tendon(s) of the rotator cuff of unspecified shoulder

Ideally the physician will document whether the strain affects the right or left shoulder; use of the unspecified code is reserved for cases when the laterality is not described.

If the patient is seen in the global period for the injury, then the 7th character D is applied to indicate routine healing following active treatment of an injury.

If the surgery was done to treat a chronic or degenerative condition coded from the M chapter, you will report Z47.89, Encounter for other orthopedic aftercare, provided the follow-up is uncomplicated.

*This response is based on the best information available as of 02/4/16.