Home Health ICD-9/ICD-10 Alert

Fracture care won't always earn case mix points.

You may be able to earn case mix points for your orthopedic patients who require therapy as part of their care, but figuring out when the points are available and how to code for them isn't always easy.

Remember five simple steps to help keep things straight.

Patients receiving care for orthopedic disorders can bring case mix points, but only in two instances, says Lisa Selman-Holman, JD, BSN, RN, HCSD, COS-C, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas; (1) If they have a primary or secondary diagnosis that falls under the Ortho 1 -- Leg case mix group and also have a stageable pressure ulcer; (2) If they have a primary or secondary diagnosis that falls under the Ortho 1 -- Leg or Ortho 2 -- Other orthopedic disorders case mix groups and they are receiving IV or parenteral therapy in the home.

Patients receiving aftercare for fractures frequently don't meet the criteria to earn case mix points in M1024, says Jan McLain, RN, BS, LNC, HCS-D, COS-C, with Adventist Health System Home Care in Port Charlotte, Fla. "There is controversy as to whether a fracture code should be included in M1024 if it does not meet the case mix equations for inclusion. Can you explain the logic for including such fracture codes in M1024?" Mclain asks.

Although fractures may not earn case mix points in M1024, listing them here can still provide risk adjustment, Selman-Holman says.

So how do you know when to complete M1024 for case mix points when you're providing aftercare for an orthopedic patient? McLain shares  her process (Note: read on to see coding examples that illustrate these steps.):

1. Determine what procedure was done and whether it "treated" or "resolved" the underlying problem.

2. Determine whether the care after the procedure appears "routine" to the current point in time.

3. Determine whether the case is therapy-only or if it's a medical case.

4. Select the appropriate V code for the care you will provide. If the procedure did not resolve the underlying problem "condition or etiology," also include the numeric code for the problem as an active diagnosis.

5. If the underlying reason for the surgery was resolved by the surgery, determine whether the underlying reason for the surgery is a case mix diagnosis and complete M1024 with this resolved condition code if appropriate.

Even when you're coding for the same type of orthopedic aftercare, the details of the case will change the codes you list -- and the case mix points you can earn. Consider the patient receiving aftercare for a healing traumatic hip fracture.

Coding Example: You are providing aftercare for a healing traumatic hip fracture. Your patient is receiving enteral feedings via a G tube. He had an open reduction internal fixation. For this patient, you would list V54.13 (Aftercare for healing traumatic fracture of hip) as the primary diagnosis, McLain says. Unfortunately, even though the fracture code falls in the Ortho 1 group, the response to M1030 is 3 (Enteral) so you won't earn any case mix points for placing the fracture code in M1024.

Another example: You are providing aftercare for a healing traumatic hip fracture in this example, too. But this patient is receiving IV antibiotics for a MRSA infection in the surgical wound from a  otal hip replacement done to correct the fracture. This is not routine aftercare for the nursing services as the focus of care for the nurse in an infected surgical wound and IV antibiotics, because of the complication of the infected surgical wound, McLain says. In this case, you would list 998.59 (Other postoperative infection), 041.12 (Methicillin Resistant Staphylococcus aureus), and a numeric code to report the need for therapy services such as abnormal gait (781.2), McLain says.

You wouldn't earn any additional case mix points for the fracture in this case either.

As with the healing traumatic fracture of the hip, it's the nuances of the case that make the difference for aftercare of a knee replacement. Whether you'll earn orthopedic case mix points -- and where they will come from can vary from patient to patient.

Coding example: You're providing aftercare for a total knee replacement due to osteoarthritis of the knee (715.36). List V54.81 (Aftercare following joint replacement) to indicate the joint replacement followed by V43.65 (Organ or tissue replaced by other means; joint; knee) for the location of the surgery, McLain says.

Now, suppose this patient also has a stage 1 pressure ulcer on the left heel. Because 715.36 is an Ortho 2 diagnosis and not Ortho 1, the patient doesn't meet the requirements for Ortho case mix points, McLain says. So 715.36 would not earn points in M1024 or be placed in active diagnoses because the diagnosis (osteoarthritis) was resolved by the surgery.

One last example: Your patient has had a total knee replacement due to a septic knee joint (711.96). This patient also has a stage 1 pressure ulcer on the heel. Code 711.96 is an Ortho 1 diagnosis, and the patient also has a pressure ulcer. In this case, you would list 711.96 in M1024 for additional case mix points, McLain says.