ICD 10 code for gout
ICD 10 code for gout is a billing code used by physical therapists for a certain form of arthritis that is a common cause of pain and functional impairments. Physical therapy is an excellent treatment option for individuals with arthritis. Gout is a complex form of arthritis characterized by sudden, severe bouts of joint swelling, pain, warmth, redness, and tenderness.
Gout attacks are most common in the joint at the base of the big toe but can occur in any joint. Ankles, knees, fingers, wrists and elbows may be affected by gout as well. An attack of gout typically occurs suddenly. Many gout sufferers report waking in the middle of the night with pain, heat, and redness in a joint so severe that even the bedsheet touching the area is unbearable.
An accumulation of needle-like urate crystals in the joint causes the inflammation and pain characteristic of gout. These urate crystals form in response to an imbalance in either the production or excretion of uric acid.
Several factors can increase the likelihood of developing gout:
- Male sex
- Post-menopausal status in women
- Medications including low dose aspirin, ACE inhibitors and anti-rejection medications for post-organ transplant patients
- A personal history of uncontrolled high blood pressure, diabetes, metabolic syndrome, or heart and kidney disease
- A family history of gout
Joint erosion causing prolonged pain and functional impairments can develop if gout is not treated. Medication management is often a first line treatment for gout but physical therapists also play a role in the management of this condition. Physical therapists can work to restore joint range of motion, manage joint pain and inflammation, educate patients on the use of splints or assistive devices to improve comfort, assist with lifestyle modifications that can reduce the risk for recurrent gout and apply interventions that can improve their patients’ function.
Just like when treating any condition, it is important you bill accurately for the treatment of gout in order to receive timely and accurate payment. One step in this process is selecting and submitting the correct ICD 10 diagnosis codes. If you, like many therapists, have some experience searching for and selecting ICD-10 codes but don’t have a great understanding of the who, what, when and why these codes are used, see the next section for an ICD-10 code primer. Following this introduction we will discuss the ICD10 code for gout in more detail.
An introduction to ICD-10 Codes
Who: All HIPAA-covered entities are required to submit ICD-10 codes if seeking reimbursement for services from an insurance company. This includes physical therapists.
What: The International Classification of Disease, 10th Revision (ICD-10) is a set of diagnosis, symptom, and procedure codes that physical therapists use daily in their practice. In 2015 physical therapists and all other HIPAA-covered healthcare providers transitioned from the ICD-9 to the current version, ICD-10. ICD-10 codes are alphanumeric codes. They begin with a letter and are always between three and seven characters with a decimal point placed after the third character.
The more characters it has, the more specific it is. Each code follows the following structure:
- Characters 1-3 indicate the category of the diagnosis
- Characters 4-6 indicate etiology, anatomic site, severity or other clinical detail
- Character 7 is an extension value, for example:
- A: Initial encounter (anything related to care of the initial injury)
- D: Subsequent encounter (anything related to the phase of routine care of the injury while the patient recovers–this usually refers to rehabilitation)
- S: Sequela (other conditions that may result from the presence of the primary condition)
Note, for fracture care, there are several more extensions ( example: P, G, K, which signify malunion, delayed healing, or nonunion for a subsequent encounter)
When: ICD-10 codes must be submitted with relevant documentation whenever reimbursement is sought for covered services either by the healthcare entity itself or by a patient.
Why: While it may seem like an extra step in an already detailed process of documentation and billing, ICD-10 codes are required for a specific reason. Not only do they identify a medical diagnosis, but perhaps more importantly, they help insurance companies understand why the care you are providing is medically necessary and therefore, reimbursable.
Acute and chronic ICD code for gout
When selecting an ICD 10 code for gout, the code with the highest number of applicable characters should be chosen, at least on the first visit. Greater specificity is more likely to lead to reimbursement but it should always be supported by the patient’s medical record and clinical knowledge of the patient’s condition.
Many three and even sometimes four digit codes can be found for a given condition when searching a reputable database like ICD10 Data, but if a more detailed code is available, this code may not be reimbursable by insurance.
This ICD 10 code for gout is used when the patient is presenting with an acute gout attack or gout flare.
This ICD 10 code for gout is used when the patient is presenting with chronic gout.
Are these codes billable?
Each ICD 10 code for gout in their three digit format is considered too nonspecific for billing/reimbursement purposes, but there are codes with more digits that are more specific and therefore reimbursable. When you search the code M10 or M1A you will see a long list of more specific codes that are divided into affected body parts as well as laterality, when indicated.
These codes can be found for the following areas:
- Shoulder
- Elbow
- Wrist
- Hand
- Hip
- Knee
- Ankle and foot
- Vertebrae
- Multiple sites
You can also use an ICD 10 code for gout that specifies both location and cause of gout if you happen to know the cause.
These include gout induced by:
- Lead
- Drugs
- Renal impairments
- Other
- Idiopathic
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Additional ICD 10 code for gout considerations
In addition to documenting the ICD 10 code for gout as the medical condition, you want to ensure you are documenting the functional limitations caused by this condition. Be sure to assess, measure and document functional impairments that impact your patient’s ADLs, mobility and ability to perform job, caretaking or recreational activities as this is the information insurance companies want to see when they review your documentation.
A few examples of codes that may also be relevant to the care of patients with gout include:
- Z74.09: Impaired mobility
- R26.89: Painful gait/other abnormalities of gait and mobility
- R26.2: Difficulty walking
Stay up to date with code changes
The Centers for Medicare and Medicaid Services publish an updated list of codes each year to go into effect October 1 and remain in effect until September 30 of the following year. Sites like ICD10 Data can also be helpful in identifying code changes once they update their list as announced on their homepage.
Resources
While successfully treating a patient with gout may require hard work on your part, managing the billing, ICD 10 codes for gout, patient scheduling and documentation doesn’t need to be. TheraPlatform is an all-in-one EHR, practice management and teletherapy solution for therapists. Sign up for a 30-day trial with no credit card required. Cancel anytime.
More resources
- Therapy resources and worksheets
- Therapy private practice courses
- Ultimate teletherapy ebook
- The Ultimate Insurance Billing Guide for Therapists
- The Ultimate Guide to Starting a Private Therapy Practice
