Musculoskeletal condition M71.38 — ICD-10 M71.38
Musculoskeletal condition M71.38
Overview
ICD-10 code M71.38 refers to "Other bursitis, not elsewhere classified." Bursitis is an inflammatory condition that affects the bursae—small, fluid-filled sacs located throughout the body that serve to cushion and reduce friction between bones and soft tissues, such as muscles, tendons, and skin. This particular code encompasses various forms of bursitis that do not fall under more specific classifications, making it essential for clinicians to accurately identify the underlying cause of the inflammation for effective treatment.
Bursitis can occur in several locations, including the shoulder, elbow, hip, knee, and heel. The condition may arise from repetitive motion, trauma, or underlying systemic diseases. Understanding the nuances of M71.38 is crucial for accurate diagnosis, effective management, and appropriate billing practices.
Anatomy of Bursae
Bursae are synovial fluid-filled sacs that are strategically located throughout the body to facilitate smooth movement between adjacent structures. Major bursae include:
- Subacromial Bursa: Located beneath the acromion in the shoulder.
- Olecranon Bursa: Found at the elbow.
- Trochanteric Bursa: Situated near the greater trochanter of the femur in the hip.
- Prepatellar Bursa: Located in front of the kneecap.
Biomechanics
The primary function of bursae is to reduce friction during movement. They allow for smooth gliding of muscles and tendons over bony prominences. When a bursa becomes inflamed due to overuse or injury, its ability to cushion these movements is compromised, leading to pain and restricted mobility.
Comman symptoms
Symptoms by Severity
- Mild Bursitis:
- Localized tenderness
- Mild swelling
- Pain with specific movements but no significant loss of function
- Moderate Bursitis:
- Moderate swelling
- Increased pain with movement
- Limited range of motion
- Discomfort during rest
- Severe Bursitis:
- Significant swelling and warmth over the affected area
- Severe pain even at rest
- Marked limitation in joint mobility
- Possible systemic symptoms if infection is present (fever, chills)
Red Flag
Clinicians should be vigilant for red flags that may indicate more serious underlying conditions requiring referral:
- Persistent fever or chills suggesting infection.
- Severe pain unresponsive to conservative measures.
- Signs of systemic illness (e.g., weight loss).
- Neurological symptoms associated with joint pain.
Referral to an orthopedic specialist may be warranted if conservative management fails after six weeks or if surgical intervention is indicated.
At a Glance
ICD-10: M71.38 | Category: Soft Tissue Disorders | Billable: Yes
Overview
ICD-10 code M71.38 refers to "Other bursitis, not elsewhere classified." Bursitis is an inflammatory condition that affects the bursae—small, fluid-filled sacs located throughout the body that serve to cushion and reduce friction between bones and soft tissues, such as muscles, tendons, and skin. This particular code encompasses various forms of bursitis that do not fall under more specific classifications, making it essential for clinicians to accurately identify the underlying cause of the inflammation for effective treatment.
Bursitis can occur in several locations, including the shoulder, elbow, hip, knee, and heel. The condition may arise from repetitive motion, trauma, or underlying systemic diseases. Understanding the nuances of M71.38 is crucial for accurate diagnosis, effective management, and appropriate billing practices.
Anatomy of Bursae
Bursae are synovial fluid-filled sacs that are strategically located throughout the body to facilitate smooth movement between adjacent structures. Major bursae include:
- Subacromial Bursa: Located beneath the acromion in the shoulder.
- Olecranon Bursa: Found at the elbow.
- Trochanteric Bursa: Situated near the greater trochanter of the femur in the hip.
- Prepatellar Bursa: Located in front of the kneecap.
Biomechanics
The primary function of bursae is to reduce friction during movement. They allow for smooth gliding of muscles and tendons over bony prominences. When a bursa becomes inflamed due to overuse or injury, its ability to cushion these movements is compromised, leading to pain and restricted mobility.
Causes & Risk Factors
Pathophysiology
Bursitis typically results from repetitive microtrauma or acute injury leading to inflammation of the bursa. The inflammatory response involves increased vascular permeability and accumulation of inflammatory cells within the bursa. This process can result in swelling, pain, and limited range of motion.
Causes
Common causes of bursitis include:
- Repetitive Motion: Activities that require repetitive overhead movements (e.g., painting, swimming) can lead to shoulder bursitis.
- Direct Trauma: A fall or direct blow to a joint can cause localized bursitis.
- Infection: Septic bursitis may occur when bacteria invade a bursa.
- Underlying Conditions: Conditions such as rheumatoid arthritis or gout can predispose individuals to bursitis.
Risk Factors
Key risk factors include:
- Age (increased incidence in those over 40)
- Occupation (jobs involving repetitive motions)
- Sports participation (athletes engaging in high-impact sports)
- Obesity (increased stress on joints)
Diagnostic Workup
Diagnostic Workup
A thorough history and physical examination are essential for diagnosing bursitis. Key components include:
- Patient History: Assess for recent activities, injuries, or pre-existing conditions.
- Physical Examination: Inspect for swelling, tenderness, warmth, and range of motion.
Imaging studies may be warranted if there is suspicion of other pathologies:
- X-rays: To rule out fractures or bone spurs.
- Ultrasound: To visualize fluid accumulation within the bursa.
- MRI: For detailed imaging if deeper structures are involved.
Laboratory Tests
In cases where infection is suspected, laboratory tests such as joint aspiration may be performed to analyze synovial fluid for signs of infection or crystals.
Treatment & Rehabilitation
Phase 1: Acute Inflammatory Phase (0-2 Weeks)
#
Goals:
- Reduce inflammation and pain.
#
Interventions:
- Rest from aggravating activities.
- Ice application for 15–20 minutes every few hours.
- Non-steroidal anti-inflammatory drugs (NSAIDs) as needed.
#
Exercises:
- Gentle range-of-motion exercises within pain tolerance (e.g., pendulum swings for shoulder bursitis).
Phase 2: Subacute Phase (2-4 Weeks)
#
Goals:
- Restore range of motion.
#
Interventions:
- Gradual return to normal activities as tolerated.
#
Exercises:
- Stretching exercises focusing on affected joint (e.g., wall slides for shoulder).
Phase 3: Strengthening Phase (4-8 Weeks)
#
Goals:
- Improve strength and stability.
#
Interventions:
- Introduce resistance training focusing on surrounding musculature.
#
Exercises:
- Isometric exercises progressing to isotonic exercises (e.g., shoulder external rotation with resistance bands).
Phase 4: Functional Phase (8+ Weeks)
#
Goals:
- Return to full activity levels.
#
Interventions:
- Sport-specific training or activities as tolerated.
#
Exercises:
- Plyometric exercises or functional movements related to specific sports or daily activities.
Prevention
Preventing musculoskeletal conditions such as M71.38, which encompasses other specified conditions of synovium and tendon, requires a multifaceted approach focusing on ergonomics, lifestyle modifications, and risk management. Here are some evidence-based strategies:
- Ergonomics: Implement ergonomic assessments in workplaces to ensure that the design of tasks and equipment minimizes strain on joints and muscles. Encourage the use of adjustable chairs, proper desk heights, and tools designed to reduce repetitive motion.
- Physical Activity: Promote regular physical activity that strengthens muscles and improves flexibility. Exercises such as stretching, yoga, and strength training can enhance musculoskeletal health and reduce the risk of injuries.
- Proper Body Mechanics: Educate individuals on proper lifting techniques and body mechanics to avoid unnecessary stress on joints. Training programs can help reinforce the importance of using legs rather than the back for lifting heavy objects.
- Weight Management: Encourage maintaining a healthy weight to lessen the load on the musculoskeletal system, particularly on weight-bearing joints such as the knees and hips.
- Risk Management: Identify individuals at higher risk due to occupation, age, or pre-existing conditions and provide tailored interventions. Early detection and management of symptoms can prevent further deterioration.
Coding Examples
Patient presents with persistent pain and swelling in the right wrist due to a long-standing inflammatory condition, diagnosed as synovitis. Upon examination, the physician notes tenderness and swelling around the wrist joint with no evidence of trauma. Code as M71.38 because it accurately reflects the diagnosis of "Other specified conditions of synovium and tendon," detailing that the condition is not attributed to a more specific diagnosis listed in the ICD-10-CM.
Audit & Compliance
To support medical necessity and prevent claim denials for ICD-10 code M71.38, the following key documentation elements are essential:
- Detailed Clinical History: Documentation should include a thorough history of the patient's symptoms, duration, and any prior treatments.
- Physical Examination Findings: Clear notation of physical examination results, particularly focusing on signs of synovitis, such as tenderness, swelling, and limited range of motion.
- Diagnostic Tests: If applicable, any imaging studies or lab tests that support the diagnosis should be documented, along with their results.
- Treatment Plan: A documented plan that outlines the rationale for the chosen treatment approach, including conservative management strategies and any referrals.
- Follow-up Notes: Subsequent visits should reflect the patient’s progress, response to treatment, and any changes in diagnosis or treatment plan.
Clinical Example
Subjective: A 45-year-old female patient presents to the clinic complaining of pain and swelling in her left ankle, which she reports started about three months ago after increasing her running routine. The pain worsens with activity and improves with rest. Objective: Upon examination, there is noticeable edema around the left ankle joint, and tenderness is elicited on palpation of the synovial area. Range of motion is limited due to pain, and no visible bruising or deformity is noted. Assessment: The patient is diagnosed with synovitis of the left ankle, coded as M71.38 due to the absence of traumatic injury or infection. Plan: Initiate a conservative treatment plan, including rest, ice application, and non-steroidal anti-inflammatory medications (NSAIDs). Refer the patient to physical therapy for a tailored exercise program to improve flexibility and strength. Schedule a follow-up appointment in four weeks to monitor progress.
Differential Diagnoses
When evaluating a patient with suspected bursitis (M71.38), it is important to differentiate it from other musculoskeletal conditions. Key differential diagnoses include:
- Tendinitis (M75): Inflammation of tendons; consider M75.1 for shoulder tendinitis.
- Osteoarthritis (M15): Degenerative joint disease; consider M15.9 for unspecified osteoarthritis.
- Rheumatoid Arthritis (M05): Autoimmune condition affecting joints; consider M05.79 for other specified rheumatoid arthritis.
- Fractures (S00-S99): Consider relevant codes based on specific fracture sites.
Documentation Best Practices
Accurate documentation is critical for proper billing under ICD-10 code M71.38:
- Clearly document patient history, including onset of symptoms and aggravating factors.
- Record findings from physical examination detailing location and severity of symptoms.
- Include any imaging studies performed along with their findings in your notes.
- Ensure that treatment plans are documented with clear goals and interventions outlined.
Proper coding will facilitate reimbursement processes while ensuring compliance with healthcare regulations.
Got questions? We’ve got answers.
Need more help? Reach out to us.