M40-M54 — Dorsopathies
ICD-10-CM codes M40-M54 cover dorsopathies, within diseases of the musculoskeletal system and connective tissue. The block holds 667 codes across 3 sub-blocks, of which 554 are billable and 113 are header codes that cannot be submitted on a claim. 92 of them (14%) require a 7th character.
The 7th character in M40-M54
A code in this block is not complete without its 7th character, and a missing one is a rejected claim rather than a denied one: the clearinghouse never passes it on. 92 of the 667 codes here take one.
- A
- initial encounter for fracture
- D
- subsequent encounter for fracture with routine healing
- G
- subsequent encounter for fracture with delayed healing
- S
- sequela of fracture
Risk adjustment in M40-M54
0 codes in this block map to a CMS-HCC, which means the diagnosis carries a risk-adjustment payment when it is documented and coded. Under-coding here is money left on the table; over-coding here is what audits are for.
- HCC 93 Rheumatoid Arthritis and Other Specified Inflammatory Rheumatic Disorders
- HCC 92 Bone/Joint/Muscle/Severe Soft Tissue Infections/Necrosis
- HCC 401 Vertebral Fractures without Spinal Cord Injury
What else to watch in M40-M54
- 4 codes are laterality-specific. They come in left and right pairs, and the pair is mutually exclusive on a single site: coding both without a bilateral code is a contradiction a scrubber should catch before the payer does.
- 554 codes are named in Medicare coverage policies. An LCD or NCD lists them as supporting medical necessity, or explicitly as not supporting it. Which applies depends on the MAC for your state.