A patient is admitted for shoulder replacement due to osteoarthritis of the right shoulder. The default index entry for osteoarthritis takes you to a primary osteoarthritis code. Is it appropriate to assign a code for primary osteoarthritis, if the provider has not documented it as such?
Yes, it is appropriate to assign a code for primary osteoarthritis. Assign code M19.011, Primary osteoarthritis, right shoulder. In ICD-10-CM, osteoarthritis is classified as primary, secondary and generalized. When the type of osteoarthritis is not specified, “primary” is the default.
Primary osteoarthritis is the most common form, and the condition is related to age. Typically, middle-aged adults (55-60) develop primary osteoarthritis, which is usually caused by “wear and tear.” Repetitive use of the joints over time can result in damage to the cartilage, causing joint pain and swelling.