Home Health ICD-9/ICD-10 Alert

Hint: Be sure you and the physician agree

A surgical wound may clearly be infected, but that doesn't mean you can code for a surgical complication.

A patient discharged from the hospital following surgery is often admitted to home care for postoperative teaching, wound care, or other skilled nursing or therapy services. Your clinicians will want to focus on patient care, so make it easy for them to navigate the coding process.

Aftercare V codes are used to describe the focus of care after surgery of a particular system, following amputation, or following surgical or other treatment of a traumatic or pathological fracture, says Chapel Hill, N.C.-based clinical consultant Judy Adams with the Larson Allen Health Care Group.

Concentrate on finding the code that best describes the major focus of the care plan -- taking all disciplines into consideration, says consultant Pat Sevast with American Express Tax and Business Services in Timonium, Md. You may need to use an aftercare code to give yourself a better picture of the overall plan and then follow it with more specific codes.

How it works: Look at two patients who both had joint replacement surgery and were discharged to home care, Sevast says. Patient A has a plan of care that focuses mainly on therapy, with only a few nursing visits. Here the primary code is likely to be V57.1 (Other physical therapy), followed by 781.2 (Gait abnormality), followed by V54.81 (Aftercare following joint replacement).

Patient B has an open incision, and nursing will be making the most visits, with PT also involved for therapy. For a better picture of the overall care plan, the primary diagnosis might be V54.81, followed by V58.3 (Attention to sutures and dressings), followed by V57.1.

Important point: V codes can be used for both nursing and therapy, Sevast adds. Aftercare codes are used only when the patient doesn't have any complications from the surgery, says Sue Prophet-Bowman with the American Health Information Management Association in Chicago. For example, V54.81 would be appropriate when you are providing the care normally expected after this surgery.

But every patient does not have to have a V code, Adams reminds clinicians. Postoperative complications always supercede aftercare V codes, since they are acute medical conditions and more intense than aftercare, she adds.

If the patient has a complication such as an infection or wound dehiscence, you would look instead to the codes for the complication, Bowman says. Complications affecting multiple sites or body systems are generally found in categories 996-999 (Complications of surgical and medical care). Complications affecting specific sites are classified in the appropriate ICD-9 chapter, she says.

If you're considering using a postoperative complication code, Bowman offers these tips:

1. A postoperative complication must arise during or result from a procedure, but must not be something you would routinely expect to occur.

2. There must be a cause-and-effect relationship between the procedure and the complication.

3. The physician must document the condition as a complication. The agency can't just see that the incision is infected and code for it.

4. Physicians often don't document complications well, Bowman says, which can make it tricky for agencies. But you can discuss the situation with the physician and document the physician's statement as a verbal order, she says.

5. If the complication code is too general and a specific code exists for the condition, assign an additional code for the specific condition -- but sequence the complication code first, followed by the specific condition code, Bowman says.