ICD-10: M25.521, M25.522, M25.561, M25.562
History—Comprehensive: The history of present illness is extended, the review of systems is complete, and the past medical, family and social history are documented. All three of the HPI, ROS and PFSH are needed to achieve the history level as comprehensive.
Examination—Detailed: This level for a 1997 musculoskeletal is detailed. To document for a comprehensive level; there must be documentation of gait and stance. Also, there must be documentation for at least four body areas including all of the following:
- Inspection, percussion and/or palpation with notation of presence of any misalignment, asymmetry, crepitus, defects, tenderness, masses or effusions;
- Assessment of range of motion with notation of any pain, crepitus or contracture;
- Assessment of stability with notation of any dislocation subluxation or laxity;
- Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements.
Medical decision making (MDM)—Moderate complexity: The number of problems is extended—there is one new problem with additional workup planned as an X-ray of both shoulders and both knees were ordered. The level of risk is moderate for the prescription drug management, which is moderate. Only two out of the three components are needed for the MDM moderate level so it is permissible to disregard the lowest component.
This is a new patient visit; the history is comprehensive, the exam is comprehensive, and the medical decision making is moderate. When the visit is a new patient or consultation, all three areas are needed. This means the lowest area, which is the medical decision making, make this visit a level three visit.
When using the 1997 musculoskeletal exam guidelines, specific elements must be documented to obtain a comprehensive exam. The 1997 guidelines for a musculoskeletal comprehensive exam state: “All four of the elements identified by a bullet must be performed and documented for each of the anatomic areas. For all three lower levels of examination (e.g., problem focused, expanded problem focused and detailed), each element is counted separately. For example, assessing range of motion in two extremities constitutes two elements.”
Keep in mind all elements identified with a bullet must be documented and only one from the other systems should be examined.
M25.50 is not multiple joint pain; it is joint pain unspecified. An unspecified code should not be used on claims unless there is a Not Other Specified (NOS). So each joint diagnosis must be coded out.
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, via email at [email protected] or call 404-633-3777 x820.
