Find information on osteoarthritis diagnosis, including clinical documentation tips, medical coding (ICD-10-CM codes M15-M19, SNOMED CT), healthcare guidelines, and best practices for accurate osteoarthritis documentation. Learn about common osteoarthritis symptoms, diagnostic criteria, and relevant medical terminology for effective communication in healthcare settings. This resource provides support for accurate and efficient osteoarthritis coding and documentation.
Also known as
Osteoarthritis
Degenerative joint disease characterized by cartilage loss.
Arthopathies
Disorders affecting joints including inflammatory and non-inflammatory types.
Dorsalgia and low back pain
Pain and other symptoms related to the back, often associated with osteoarthritis.
Other joint disorders
Joint derangements and other specific joint conditions excluding osteoarthritis.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the osteoarthritis primary?
Yes
Site of primary OA?
No
Is it post-traumatic?
When to use each related code
| Description |
|---|
| Osteoarthritis |
| Rheumatoid Arthritis |
| Gout |
Missing or incorrect laterality (right, left, bilateral) for osteoarthritis can lead to claim denials and inaccurate reporting.
Coding osteoarthritis requires specific joint documentation. Unspecified joint codes can cause claim rejections and affect quality metrics.
Distinguishing between primary and secondary osteoarthritis is crucial for accurate coding, impacting reimbursement and data analysis.
Patient presents with complaints consistent with osteoarthritis (OA), characterized by joint pain, stiffness, and reduced range of motion. The patient reports [duration of symptoms] of [specific joint location] pain, described as [character of pain: e.g., aching, sharp, throbbing]. Symptoms are [aggravating factors: e.g., worsened by activity, relieved by rest] and associated with [associated symptoms: e.g., crepitus, swelling, morning stiffness lasting [duration]]. Physical examination reveals [objective findings: e.g., tenderness to palpation, bony enlargement, limited range of motion in the affected joint, crepitus on movement]. Radiographic imaging of the [affected joint] demonstrates [radiographic findings: e.g., joint space narrowing, osteophytes, subchondral sclerosis]. These findings support a diagnosis of osteoarthritis. Differential diagnoses considered include rheumatoid arthritis, gout, and pseudogout. Based on the clinical presentation, imaging results, and patient history, the diagnosis of osteoarthritis is most likely. The patient was educated on osteoarthritis management, including non-pharmacological interventions such as weight management, exercise, and physical therapy. Pharmacological management options, including acetaminophen, NSAIDs, and topical analgesics, were discussed. The patient was also advised on joint protection strategies and the potential benefits of assistive devices. Follow-up was scheduled to monitor symptom progression and adjust the treatment plan as needed. ICD-10 code M19.9 (Osteoarthritis, unspecified site) or more specific site code if applicable, will be used for billing and coding purposes.