Published 3/1/2014
Margaret M. Maley, BSN, MS

ICD-10: The Documentation Is in the Details

The format and structure of ICD-9 and ICD-10 codes (Fig. 1) are so completely different that it is difficult to believe that in just a few months they will be used for the same purpose. When educating AAOS members about the transition to ICD-10, I and others have found that is it best to start with something familiar.

Then and now
In ICD-9, many orthopaedic codes began with the number 7 or 8. These numbers correspond with the chapters in ICD-9 that include diagnosis codes of a particular kind or category. In ICD-9, codes beginning with the number 7 are found in chapter 13: Diseases of the Musculoskeletal System and Connective Tissue and range from 710 to 739.

In ICD-10, most of those same diagnoses are still found in chapter 13, and the chapter still has the same name, but the codes range from M00 to M99.

In general, the diagnoses in the 710–739 range under ICD-9 will begin with the letter M under ICD-10. Codes for osteoarthritis of the knee, pain in the hip, and degenerative meniscus all began with the number 7 in ICD-9. Those same conditions, when not the result of an acute injury, will continue to be found in the musculoskeletal chapter in ICD-10, but will begin instead with the letter M.

In ICD-9, acute injuries are found in the Injury chapter and begin with the number 8. In ICD-10, those same diagnoses will still be found in the Injury chapter, but will begin with the letter S. These include tear of the anterior cruciate ligament, acute meniscal injury, SLAP lesion, hip fracture without osteoporosis, and all other traumatic fractures.

Pathologic and fragility fractures, however, will be found in the musculoskeletal chapter in ICD-10 and will begin with the letter M. In addition, in ICD-10, a single code is used to report both the exact location of the pathologic fracture and the cause (age- or drug-induced, neoplasm, or other).

Table 1 compares the initial character(s) in ICD-9 and ICD-10 codes of interest to orthopaedic surgeons. There are some exceptions, but referring to Table 1 may make the transition to ICD-10 easier and the code set seem more familiar.


ICD-10 codes are highly specific and will require additional physician documentation. According to a 2008 study by Nachimson Advisors, LLC on the impact of implementing ICD-10, the more extensive documentation requirements of ICD-10 would result in a 3 percent to 4 percent increase in the time a physician spends on documentation. This extra time was not related to learning the new codes, but rather to the additional detail required by ICD-10 for documentation; therefore, this increase in clinician work will be permanent.

AAOS members should begin to fill their documentation specificity gaps now. This requires targeting the ICD-9 diagnoses that are most important to the practice’s bottom line to ensure that all of the documentation elements are present in the record when ICD-10 goes live on Oct. 1, 2014.

The first step is to run an ICD-9 frequency report of the top 25 codes by utilization or, better yet, by charges. Then, using the ICD-10-CM code set, make key documentation tables similar to those shown in Table 2 for the most frequently reported diagnoses.

Note that the shaded areas in Table 2 are not necessary to assign an ICD-9 code, but will be required under ICD-10 to assign the correct code. Providers should begin to include the more specific documentation for these diagnoses now.

Although providers have little or no control over many elements of ICD-10 implementation—including payer and clearinghouse readiness—orthopaedic surgeons can be certain that more specific documentation will be required to support code selection under ICD-10. Preparing now will help ensure the smoothest possible transition to the ICD-10 code set in October.

Margaret M. Maley, BSN, MS, is a senior consultant with KarenZupko & Associates, Inc., who focuses on CPT and ICD-10 coding education for orthopaedic practices.