On October 1, 2015, the mandated diagnosis coding system forhealth care providers in the United States converted from the International Classification of Diseases, 9th Revision (ICD-9), to the International Classificationof Diseases, 10th Revision, Clinical Modification (ICD-10-CM). Led by the World Health Organization, this revision occurred after extensive evaluation by a technical advisory panel, numerous physician groups, medical coders, and other experts. In adopting the use of the ICD-10-CM, the United States joined an international community that includes European, South American, Asian, and African countries. The differences between the ICD-9 and the ICD-10-CM are numerous. Compared with the 5-character, solely numeric codes of the ICD-9, the ICD-10-CM uses 7-character alphanumeric codes. The goal of this increased complexity was to provide health care practitioners with more accurate and specific codes to describe diagnoses.
The field of pediatric orthopedics seeks to evaluate and treat a wide spectrum of disease processes, as do numerous other fields both in orthopedic surgery and in other operative and nonoperative fields. The authors are unaware of any reports specifically evaluating the utility and specificity of ICD-10-CM codes in the pediatric orthopedic literature. They evaluated 20 diagnoses that are commonly seen in general pediatric orthopedic practice (Table 1). The goals of this study were twofold: (1) to evaluate the adequacy of these codes to describe the diagnoses and (2) to offer advice on the most appropriate code to use when the ideal code does not exist.
The 20 Diagnoses Chosen
Materials and Methods
A list of 20 diagnoses commonly seen in general pediatric orthopedic practice were chosen by 2 fellowship-trained pediatric orthopedic surgeons. The appropriate ICD-10-CM code for each diagnosis was then evaluated independently by each surgeon. The surgeons then came to a consensus about the adequacy of the codes to describe the diagnoses and agreed on an appropriate alternate code when the ideal code did not exist.
This section includes a brief summary of the ICD-10-CM codes for each diagnosis chosen.
Developmental dysplasia of the hip (DDH): Q65. Congenital dislocation as well as laterality is described, in addition to partial hip dislocation (ie, subluxation) with laterality. A dislocatable hip (ie, Barlow-positive hip) also is included, but without laterality. Both congenital acetabular dysplasia and femoral anteversion are described under other specified congenital deformities of hip, Q65.89, without laterality.
Slipped capital femoral epiphysis (SCFE): M93.0. Acute, chronic, acute on chronic, and unspecified SFCEs are described. No option for bilaterality is noted. No other classification is offered.
Legg-Calve-Perthes disease (LCP): M91.1. Juvenile osteochondrosis of the head of the femur, with laterality but no bilateral option.
Femoral anteversion: Q65.89. Described under other specified congenital deformities of hip, along with acetabular dysplasia, as previously discussed.
Tibial torsion: M21.86. Described under other specified acquired deformities of lower leg, with laterality. Internal versus external torsion is not discussed.
Metatarsus adductus: Q66.2. Described under metatarsus varus, without laterality.
Patellofemoral disorder: M22.2. Described with laterality. Codes are also provided for recurrent dislocation (M22.0) as well as subluxation (M22.1).
Osgood-Schlatter disease: M92.5. Described under juvenile osteochondrosis of tibia and fibula, with laterality. Blount's disease and tibia vara are also included in this code.
Genu varum: M21.16. Described with varus deformity not elsewhere classified, with laterality, and also under M92.5, juvenile osteochondrosis of tibia and fibula. This is listed as an acquired condition. For congenital genu varum, the code Q74.1 would be used.
Genu valgum: M21.06. Described with valgus deformity not elsewhere classified, with laterality. This is listed as an acquired condition as well. Q74.1 would be used for the congenital diagnosis.
Blount's disease: M92.5. Described with juvenile osteochondrosis of tibia and fibula, with laterality. The same code is used for Osgood-Schlatter disease and tibia vara.
Tibial bowing: Q68.4. Described with congenital bowing of tibia and fibula. The direction of bowing was not discussed, and laterality was not specified.
Flexible flatfoot: Q66.5. This code includes congenital pes planus, congenital flatfoot, congenital rigid flatfoot, and congenital spastic flatfoot. No laterality is given.
Tarsal coalition: Q66.89. Described with other specified congenital deformities of feet. This code includes congenital hammer toe, congenital asymmetric talipes, congenital clubfoot not otherwise specified, and congenital talipes not otherwise specified.
Polydactyly: Q69.2. Described under accessory toe(s)/accessory hallux; Q69.9, polydactyly, unspecified/supranumerary digit(s) not otherwise specified; and Q70.4, polysyndactyly. No laterality is given.
Accessory navicular: No specific code was found.
Clubfoot: Q66.0. Described by congenital talipes equinovarus, without laterality.
Tight heel cord: M62.46. Described under contracture of muscle, lower leg, with laterality. M67.0, short Achilles tendon (acquired) with laterality is also an option.
Cavovarus: Q66.7. No specific code. The most similar code is congenital pes cavus without laterality.
Calcaneovalgus: Q66.4. This diagnosis is described with congenital talipes calcaneovalgus without laterality.
Of the 20 diagnoses evaluated, 65% (13 of 20) offered left and right options. The remaining 35% did not offer an option for laterality. When laterality was not included, the authors found that only 7 (35%) diagnoses were adequately described by the ICD-10-CM coding system. One diagnosis did not have a code, and several other codes lacked specificity.
This section includes a critique of the codes available for each diagnosis and recommendations for which codes to use in ambiguous cases.
Developmental dysplasia of the hip (DDH): Congenital hip dislocation, subluxation, and Barlow-positive hips are well described with these codes. The use of Q65.89, congenital acetabular dysplasia and femoral anteversion, is less than ideal and lacks specificity because these 2 diagnoses can be found in different patient populations. There is no separate code for teratologic dislocation. The authors recommend using Q65.9, congenital deformity of hip, unspecified.
Slipped capital femoral epiphysis (SCFE): The condition is described in the ICD-10-CM as “slipped upper femoral epiphysis,” although this is not the commonly used term. Although acute, chronic, acute on chronic, and unspecified SCFEs are described, the stability of slips is not. The stability of slips is strongly associated with certain complications (ie, osteonecrosis) that affect long-term patient outcomes.1 Descriptors for right and left are included, but no option for bilateral is noted; therefore, each hip must be listed separately in bilateral cases.
Legg-Calve-Perthes disease (LCP): Laterality is specified, but there is no bilateral option, so again, in bilateral cases, a code for each hip must be used. Otherwise, this disease is adequately described by the code.
Femoral anteversion: As with DDH, this diagnosis is described with other specified congenital deformities of hip, along with acetabular dysplasia. Although these 2 diagnoses are commonly seen with DDH, femoral anteversion is also a common cause of intoeing in the older child. Ideally, these would be separate codes, and additional codes would be used to describe femoral retroversion and laterality.
Tibial torsion: Internal vs external torsion is not discussed. Both diagnoses are commonly seen, and although internal tibial torsion typically resolves in toddlers, external torsion does not.2 The same code also describes genu recurvatum, so specificity is lacking. Preferably, separate codes would be used to describe internal and external torsion with laterality.
Metatarsus adductus: This condition is adequately described by code Q66.2, although a laterality option would be ideal. Another available code is Q66, other congenital varus deformities of feet.3
Patellofemoral disorder: This code lacks specificity because a wide range of patellofemoral issues contribute to pain. Ideally, there would be separate codes for patellofemoral pain and general knee pain as well.
Osgood-Schlatter disease: Specificity is poor because the code describes this common diagnosis as well as Blount's disease and tibia vara.
Genu varum/genu valgum: Codes are available for the congenital and acquired conditions, both of which are seen in practice. Code Q74.1, congenital malformation of the knee, is used to describe not only congenital genu varum/valgum but also multiple congenital patellar abnormalities, so specificity is poor. The code for acquired genu varum also may be mistakenly used to describe Blount's disease, although a more specific code exists (M92.5). Otherwise, these diagnoses are described adequately by the code.
Blount's disease: See Osgood-Schlatter disease. Ideally, separate codes also would be available for infantile and adolescent Blount's disease because they are different disease processes.
Tibial bowing: The direction of bowing is not described. Although anterolateral tibial bowing may suggest congenital pseudarthrosis and may require bracing, posteromedial bowing can be observed and anteromedial bowing may suggest fibular hemimelia.3 Ideally, the coding would allow the provider to describe the diagnosis more accurately.
Flexible flatfoot: Pes planus is a common diagnosis. Although asymptomatic flexible flatfoot is benign, rigid flatfoot is not and typically merits further evaluation.4 Ideally, these 2 diagnoses would have different codes.
Tarsal coalition: This diagnosis is described under an additional nonspecific code that also describes other conditions. Specificity is again lacking.
Polydactyly: No further detail is allowed (preaxial, postaxial). Otherwise, this diagnosis is adequately described by the code.
Accessory navicular: The authors found no specific code and recommend the use of code Q66.9, congenital deformity of feet, unspecified.
Clubfoot: Although a specific clubfoot code exists, no laterality is given. The authors also recognize that nonidiopathic clubfoot (ie, atypical, syndromic, associated with arthrogryposis) is a more complex diagnosis that can be associated with prolonged casting and an increased rate of recurrence.5 In this situation, addition of the appropriate code for the underlying diagnosis is recommended.
Tight heel cord: This diagnosis is adequately described by either code.
Cavovarus: Although a code is available for congenital pes cavus, another code is used for acquired clubfoot (M21.541). Typically, cavovarus foot is an acquired condition that occurs as a result of cerebral palsy or another neuromuscular disorder (ie, Charcot-Marie-Tooth disease).6 The authors recommend use of the code for acquired clubfoot.
Calcaneovalgus: This diagnosis is adequately described by the code for the congenital type. If the condition was not present at birth, another applicable (but nonspecific) code would be M21.6, other acquired deformities of foot.
The authors recognize that no coding system to describe such a diverse and complex spectrum of diagnoses will be perfect. The ideal system would be complete, specific, and uniform and would provide adequate information for both billing and future research.
Although completeness in such a large system can be difficult to achieve, the authors expected that these 20 commonly used codes would be well represented. Although most of the codes were complete, several were not. The authors identified a common pediatric orthopedic diagnosis that had no code and required the use of a nonspecific code (accessory navicular). On evaluation of the specificity of these codes, some were found to be appropriate and others were not. In several cases, vastly different disease processes were described by the same code (acetabular dysplasia/femoral anteversion, Osgood-Schlatter disease/Blount's disease). Obviously, this situation is not optimal in a system designed for accuracy. In addition, other conditions, although described by a code, were generic. These include clubfoot and tibial torsion, both of which can represent a wide spectrum of disease and even normal physiologic development.3,5 Further, the use of laterality is inconsistent throughout these diagnosis codes. Ideally, the use of laterality would be uniform. In several cases, descriptors for right, left, and unspecified are included, but there is no option for bilateral. In these instances, the provider would be required to list each side separately. This problem could be resolved with elimination of the unspecified code and the option of indicating left, right, or bilateral for all extremity codes.
This study was not without limitations. The authors did not attempt to evaluate all codes in the field of pediatric orthopedics. Instead they chose 20 common general pediatric orthopedic diagnoses. The evaluation of spine, tumor, or fracture codes is beyond the scope of this article. The diagnoses that were included were those that the authors believed that any provider treating children would evaluate, not only pediatric orthopedists but also primary care providers. In addition, the critiques were provided by only 2 physicians and were subjective. However, both of the authors were fellowship-trained pediatric orthopedic surgeons, and the senior author has several years of experience in the field of medical coding and has served on numerous coding committees.
The goal of this article was not simply to identify flaws in the ICD-10-CM coding system. Rather, the authors sought to acknowledge and discuss the various shortcomings of this new system in the field of pediatric orthopedics. No doubt numerous providers have noted similar inconsistencies. The authors' goal was to provide guidance in appropriate coding in cases of ambiguity.
The American Academy of Orthopaedic Surgeons Coding, Coverage and Reimbursement Committee is a useful resource for providers seeking to offer revisions and updates to the ICD-10-CM. This committee includes 12 representatives from various subspecialty organizations, including the Pediatric Orthopaedic Society of North America. These representatives can gather information from members about diagnosis codes that are missing or that do not describe specific conditions correctly and share their findings with the Centers for Medicare and Medicaid Services or the World Health Organization in an effort to improve the coding system.
Although the ICD-10-CM provides more coding options than the ICD-9, a small sample of common diagnoses identified several shortcomings. The authors hope that refinements to the system will include more uniform use of laterality, individual codes for separate diagnoses, and the inclusion of codes for common conditions to avoid the use of unspecified codes.
- Aronsson DD, Loder RT, Breur GJ, Weinstein SL. Slipped capital femoral epiphysis: current concepts. J Am Acad Orthop Surg. 2006;14(12):666–679. https://doi.org/10.5435/00124635-200611000-00010 PMID: doi:10.5435/00124635-200611000-00010 [CrossRef]17077339
- Lincoln TL, Suen PW. Common rotational variations in children. J Am Acad Orthop Surg. 2003;11(5):312–320. https://doi.org/10.5435/00124635-200309000-00004 PMID: doi:10.5435/00124635-200309000-00004 [CrossRef]14565753
- Johnston CE, Young M. Disorders of the leg. In: Herring JA, ed. Tachdijan's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children. 5th ed. Philadelphia, PA: Elsevier Saunders; 2014:741–757.
- Bouchard M, Mosca VS. Flatfoot deformity in children and adolescents: surgical indications and management. J Am Acad Orthop Surg. 2014;22(10):623–632. https://doi.org/10.5435/JAAOS-22-10-623 PMID: doi:10.5435/JAAOS-22-10-623 [CrossRef]25281257
- Ricco AI, Richards BS, Herring JA. Disorders of the foot. In: Herring JA, ed. Tachdijan's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children. 5th ed. Philadelphia, PA: Elsevier Saunders; 2014:770–834.
- Schwend RM, Drennan JC. Cavus foot deformity in children. J Am Acad Orthop Surg. 2003;11(3):201–211. https://doi.org/10.5435/00124635-200305000-00007 PMID: doi:10.5435/00124635-200305000-00007 [CrossRef]12828450
The 20 Diagnoses Chosen
|Hip Developmental dysplasia of the hip Slipped capital femoral epiphysis Legg-Calve-Perthes diseaseRotational abnormalities Femoral anteversion Tibial torsionKnee Patellofemoral disorder Osgood-Schlatter diseaseDeformity Genu varum Genu valgum Blount's disease Tibial bowingFoot and ankle Flexible flatfoot Tarsal coalition Polydactyly Accessory navicular Clubfoot Tight heel cord Cavovarus Calcaneovalgus Metatarsus adductus|