Home Health ICD-9/ICD-10 Alert

Pop quiz: Which aftercare code should you list when your patient's fracture is treated with a joint replacement?

For example: If your patient has multiple fractures, the clinician will need to determine which fractures are the worst or need the most intervention so they can be sequenced first, says Judy Adams, RN, BSN, HCS-D, COS-C, president and CEO of Adams Home Care Consulting in Chapel Hill, N.C.

Tip: If your patient has multiple fractures, code for them by site rather than as "multiple" fractures, says Joan L. Usher, BS, RHIA, COS-C, ACE, with JLU Health Record Systems in Pembroke, Mass. You'll find codes that report a combination of fractures such as 819.x (Multiple fractures involving both upper limbs and upper limb with rib[s] and sternum) in your ICD-9 manual, but the coding guidelines advise you to use these codes only when there is insufficient detail or specificity in the medical record or if you face a limit on the number of codes pertinent to clinical data that you can report.

Once you know the focus of your care, you'll need to determine whether the fractures are traumatic or pathological and what type of treatment they may have already received, Adams says. Certain fractures, like the pelvis or ribs are frequently allowed to heal without surgical or other treatment, she says. Other fractures may be treated surgically with an Open Reduction Internal fixation (ORIF), casted, or splinted.

Regardless of how the fractures are treated or if they are left to heal on their own, once a fracture is diagnosed, it becomes a "healing" fracture rather than an acute fracture, Adams says. For home health agencies, that means you will never code an acute fracture as a current home health diagnosis in M1020 or M1022.

Instead, look to the aftercare codes such as V54.1x (Aftercare for healing traumatic fracture) or V54.2x (Aftercare for healing pathological fracture).

Try this: You can list the acute fracture in the inpatient diagnoses (M1010), the conditions requiring a change in medications or treatment regimen (M1016) or as a payment diagnosis for potential case mix points in M1024, Adams says.

Coding scenario: Your patient sustained a pathologic fracture of her femur when rolling over in bed. Your agency will be providing skilled nursing, physical therapy, and occupational therapy. Your patient also has senile osteoporosis and had a vertebral pathologic fracture 1 year ago. Code for this patient as follows, Adams says.

M1020a: V54.23 (Aftercare for healing pathologic fracture of hip), M1024 733.14 (Pathological fracture of neck of femur);

M1022b: 733.01 (Senile osteoporosis);

M1022c: V13.51 (Personal history of pathologic fracture).

In this case, aftercare for your patient's pathologic hip fracture is the focus of your care, so you'll list V54.23 in M1020a, paired with 733.14 in M1024.

Although you're listing the acute fracture code in M1024, it won't bring you case mix points because this patient doesn't also have a pressure ulcer and isn't receiving IV or parenteral nutrition at home, says Usher. But listing 733.14 may impact your risk adjustment.

Follow this with 733.01 to report your patient's senile osteoporosis as a co-morbidity. And finally, list a history code for her vertebral pathologic fracture because it will impact the care you provide.

Tip: Some fractures, especially of the hip, shoulder or knee are actually treated with a joint replacement, Adams says. In such cases, the appropriate aftercare code is V54.81 (Aftercare following joint replacement) rather than the aftercare of a healing fracture code because the post acute care is more aligned with the joint replacement aftercare and the fracture is definitely no longer present, she says. And don't forget to code the appropriate V43.6x (Organ or tissue replaced by other means; joint) code to indicate the joint affected.

Note: Look for more fracture-coding tips including how to code fractures in therapy-only cases and what to do with late effects of fractures in part 2 of this article which will run in the Jan. 2011 issue of Home Health ICD-9 Alert.