Documenting Osteomyelitis - Symptoms, Diagnosis and ICD-10 Codes

Documenting Osteomyelitis Symptoms, Diagnosis and ICD-10 Codes Osteomyelitis refers to a bone infection that occurs when bacteria or fungi invade a bone. Here are the ICD-10 codes for documenting this condition.

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Osteomyelitis is an inflammation of the bone or bone marrow. Also called bone infection, this condition occurs when bacteria or fungi enter the bone tissue through the bloodstream or spread from nearby tissue either due to an injury or surgery. The condition affects both children and adults, (although in different ways). In children, these infections most commonly affect the long bones in the leg and upper arms. For adults it affects the hips, spine, and feet. Generally, your bones are resistant to infection. However, for osteomyelitis to occur, a situation that makes your bones vulnerable must be present. A few conditions and circumstances that can potentially increase your chances of osteomyelitis include recent injury or orthopedic surgery, diabetic disorders, intravenous drug usage, hemodialysis, Peripheral Arterial Disease (PAD, often related to smoking), rheumatoid arthritis, sickle cell disease, artificial joints and trauma to the tissue surrounding the bones.

Bone infections can occur suddenly or develop over a long period of time. If not treated properly, the condition can cause the infection to spread and leave a bone permanently damaged. From a medical coding service provider’s point of view, proper documentation by the physician specifying the exact location and type of bone infection as well as any complications or manifestations is indispensable for proper code selection.

Reports suggest that osteomyelitis affects 2 out of every 10,000 people in the United States.

It is estimated that about 80 percent of cases develop due to an open wound. Osteomyelitis involves three different types. Acute osteomyelitis develops within 2 weeks of an injury, initial infection, or the start of an underlying disease. Sub-acute osteomyelitis infection develops within 1–2 months of an injury, initial infection, or the start of an underlying disease. In chronic osteomyelitis, the infection may begin at least 2 months after an injury, initial infection, or the start of an underlying disease. Treatment depends on the type of infection, its severity, and the extent of bone damage (if any).

What Causes Osteomyelitis?

Most cases of osteomyelitis are caused by “Staphylococcus aureus” (a type of staph bacteria) found on the skin or in the nose of even healthy individuals. An infection may initially begin in one area of the body and spread to the bones via the blood stream, open wound, an infected tissue or an infected prosthetic joint.

Common Signs and Symptoms The signs and symptoms of osteomyelitis will depend on the type and severity of infection.

Pain at the infection site is the initial symptom to appear for this condition. Some of the other symptoms include   

Fever and chills Redness in the infected area Changes in walking pattern

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Drainage from the area Irritability or generally feeling unwell Stiffness or inability to use an affected limb Swelling in the affected area

In some cases, osteomyelitis causes no visible signs and symptoms or has symptoms that are quite difficult to distinguish from other problems.

How Is Osteomyelitis Diagnosed and Treated?

Diagnosis of bone infections may generally begin with a detailed physical examination around the affected bone to check for pain, tenderness, swelling and discoloration.

Physicians may also analyze or review your previous medical history, especially if you have suffered any recent accidents, infections or undergone any operations. For people who have suffered a foot ulcer, the physician may use a dull probe to determine the proximity of the underlying bone.

To make an accurate diagnosis and to determine which germ is causing the infection, physicians may conduct a combination of several tests and procedures like blood tests, throat swabs, urine cultures, and stool analyses. Several imaging tests such as X-ray, CT (Computerized tomography) scan and MRI (Magnetic resonance imaging) scan will be done to get detailed images of bones and the soft tissues that surround them. A bone scan or bone biopsy may also be conducted to find out which type of germ has infected your bone.

Knowing the type of germ allows your physician to select a specific treatment method that works particularly well for that type of infection.

Treatments for this condition include antibiotic medications and surgical procedures to remove portions of bone that are infected or dead. Antibiotics may be administered directly or intravenously into your veins (if the infection is severe). In normal cases, antibiotics are taken for 4 to 6 weeks. However, if the infection is severe, the course may last up to 12 weeks. It is important for patients to complete the full course of antibiotics to ensure better results.

Surgery may be required for osteomyelitis to remove the portions of bone that are infected or dead. Based on the severity of the infection, osteomyelitis surgery may include the following procedures -- draining the infected area, restoring blood flow to the bone, removing diseased bone and tissue and removing any foreign objects. In some rare cases, to stop the infection from spreading further, the affected limb will be amputated.

To receive appropriate reimbursement, providers should ensure that the diagnosis codes on the medical claims for osteomyelitis infection correctly reflect their specific diagnosis.

Specialists (radiologists, orthopedists, hematologists, infectious disease physicians and

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hyperbaric medicine physicians) who treat osteomyelitis condition rely on reputable medical billing companies to code the condition accurately.

ICD- 10 Codes for Osteomyelitis ICD-10 codes include specific bones for some sites and laterality. Specific sites for subcategories M86.0-M86.6 include         

Shoulder Tibia/fibula Radius/ulna Other specified sites Multiple sites Humerus Hand Femur Ankle/foot

The following ICD-10 codes are relevant with regard to this bacterial bone infection – M86 - Osteomyelitis M86.0 - Acute hematogenous osteomyelitis 

M86.00 Acute hematogenous osteomyelitis, unspecified site  M86.01 - Acute hematogenous osteomyelitis, shoulder  M86.02 - Acute hematogenous osteomyelitis, humerus  M86.03 - Acute hematogenous osteomyelitis, radius and ulna  M86.04 - Acute hematogenous osteomyelitis, hand  M86.05 - Acute hematogenous osteomyelitis, femur  M86.06 - Acute hematogenous osteomyelitis, tibia and fibula  M86.07 - Acute hematogenous osteomyelitis, ankle and foot  M86.08 - Acute hematogenous osteomyelitis, other sites  M86.09 - Acute hematogenous osteomyelitis, multiple sites

M86.1 - Other acute osteomyelitis 

M86.10 - Other acute osteomyelitis, unspecified site  M86.11 - Other acute osteomyelitis, shoulder  M86.12 - Other acute osteomyelitis, humerus  M86.13 - Other acute osteomyelitis, radius and ulna  M86.14 - Other acute osteomyelitis, hand  M86.15 - Other acute osteomyelitis, femur

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M86.16 - Other acute osteomyelitis, tibia and fibula M86.17 - Other acute osteomyelitis, ankle and foot M86.18 - Other acute osteomyelitis, other site M86.19 - Other acute osteomyelitis, multiple sites

M86.2 - Subacute osteomyelitis 

M86.20 - Subacute osteomyelitis, unspecified site  M86.21 - Subacute osteomyelitis, shoulder  M86.22 - Subacute osteomyelitis, humerus  M86.23 - Subacute osteomyelitis, radius and ulna  M86.24 - Subacute osteomyelitis, hand  M86.25 - Subacute osteomyelitis, femur  M86.26 - Subacute osteomyelitis, tibia and fibula  M86.27 - Subacute osteomyelitis, ankle and foot  M86.28 - Subacute osteomyelitis, other site  M86.29 - Subacute osteomyelitis, multiple sites

M86.3 - Chronic multifocal osteomyelitis 

M86.30 - Chronic multifocal osteomyelitis, unspecified site  M86.31 - Chronic multifocal osteomyelitis, shoulder  M86.32 - Chronic multifocal osteomyelitis, humerus  M86.33 - Chronic multifocal osteomyelitis, radius and ulna  M86.34 - Chronic multifocal osteomyelitis, hand  M86.35 - Chronic multifocal osteomyelitis, femur  M86.36 - Chronic multifocal osteomyelitis, tibia and fibula  M86.37 - Chronic multifocal osteomyelitis, ankle and foot  M86.38 - Chronic multifocal osteomyelitis, other site  M86.39 - Chronic multifocal osteomyelitis, multiple sites

M86.4 - Chronic osteomyelitis with draining sinus 

M86.40 - Chronic osteomyelitis with draining sinus, unspecified site  M86.41 - Chronic osteomyelitis with draining sinus, shoulder  M86.42 - Chronic osteomyelitis with draining sinus, humerus  M86.43 - Chronic osteomyelitis with draining sinus, radius and ulna  M86.44 - Chronic osteomyelitis with draining sinus, hand  M86.45 - Chronic osteomyelitis with draining sinus, femur  M86.46 - Chronic osteomyelitis with draining sinus, tibia and fibula  M86.47 - Chronic osteomyelitis with draining sinus, ankle and foot  M86.48 - Chronic osteomyelitis with draining sinus, other site

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 M86.49 - Chronic osteomyelitis with draining sinus, multiple sites M86.5 - Other chronic hematogenous osteomyelitis 

M86.50 - Other chronic hematogenous osteomyelitis, unspecified site  M86.51 - Other chronic hematogenous osteomyelitis, shoulder  M86.52 - Other chronic hematogenous osteomyelitis, humerus  M86.53 - Other chronic hematogenous osteomyelitis, radius and ulna  M86.54 - Other chronic hematogenous osteomyelitis, hand  M86.55 - Other chronic hematogenous osteomyelitis, femur  M86.56 - Other chronic hematogenous osteomyelitis, tibia and fibula  M86.57 - Other chronic hematogenous osteomyelitis, ankle and foot  M86.58 - Other chronic hematogenous osteomyelitis, other site  M86.59 - Other chronic hematogenous osteomyelitis, multiple sites

M86.6 - Other chronic osteomyelitis 

M86.60 - Other chronic osteomyelitis, unspecified site  M86.61 - Other chronic osteomyelitis, shoulder  M86.62 - Other chronic osteomyelitis, humerus  M86.63 - Other chronic osteomyelitis, radius and ulna  M86.64 - Other chronic osteomyelitis, hand  M86.65 - Other chronic osteomyelitis, thigh  M86.66 - Other chronic osteomyelitis, tibia and fibula  M86.67 - Other chronic osteomyelitis, ankle and foot  M86.68 - Other chronic osteomyelitis, other site  M86.69 - Other chronic osteomyelitis, multiple sites

M86.8 - Other osteomyelitis 

M86.8X - Other osteomyelitis  M86.8X0 - Other osteomyelitis, multiple sites  M86.8X1 - Other osteomyelitis, shoulder  M86.8X2 - Other osteomyelitis, upper arm  M86.8X3 - Other osteomyelitis, forearm  M86.8X4 - Other osteomyelitis, hand  M86.8X5 - Other osteomyelitis, thigh  M86.8X6 - Other osteomyelitis, lower leg  M86.8X7 - Other osteomyelitis, ankle and foot  M86.8X8 - Other osteomyelitis, other site  M86.8X9 - Other osteomyelitis, unspecified sites

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M86.9 - Osteomyelitis, unspecified With timely treatment, most cases of osteomyelitis infections can be largely controlled.

Practicing good hygiene can help prevent or reduce the chances of developing this infection. These include - taking good care of the skin, cleaning and treating open wounds and cuts, covering the wound with a bandage, cleaning and drying amputation sites (before placing your prosthesis) and using proper footwear and protective gears (to avoid injuries related to sports activities).

Medical billing and coding can be complex and requires proper knowledge about appropriate coding, modifiers and payer-specific medical billing. A reliable medical billing and coding company can provide the necessary support to physicians to report osteomyelitis correctly on the medical claims and receive optimal reimbursement.

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