When coding for ICD 10 the diagnosis code coded should be only for what is being addressed on that date of service. ICD-10 has a great deal more codes to address specificity and laterality. This means that documentation must support the medical necessity of an ICD-10 diagnosis code.
The ICD- 9 code would be 714.0—rheumatoid arthritis
The ICD-10 codes would be M06.09—rheumatoid arthritis without rheumatoid factor, multiple sites for the office visit. This is allowed because the rheumatoid arthritis is for more than one joint—left hand, left elbow and the neck.
M06.042—rheumatoid arthritis without rheumatoid factor, left hand to support the medical necessity of the X-ray of the left hand and for the joint injection of the first finger on the left hand. Because the X-ray was only of the left hand, the code for rheumatoid arthritis without rheumatoid factor, multiple sites, for this service would not meet the specificity of this service.
For questions or information on proper coding and documentation, contact Melesia Tillman, CPC, CPC-I, CRHC, CHA, at mtillman@rheumatology.org or (404) 633-3777 x820.