Home Health ICD-9/ICD-10 Alert

Pop quiz: When does a condition become a late effect of a fracture?

We discussed the first step to coding for fractures and where to list acute fracture codes, in part 1 of this article which appeared in the Dec. 2010 issue of Home Health ICD-9 Alert. Now we'll dig in deeper to discuss how to code therapy-only fractures as well as late effects and complications of fractures.

When therapy is the only service you're providing, the Official Coding Guidelines require that a code from the V57.x (Care involving use of rehabilitation procedures) series is listed as the principal diagnosis code to show the admission is for rehabilitation, says Judy Adams, RN, BSN, HCS-D, COS-C, president and CEO of Adams Home Care Consulting in Chapel Hill, N.C. This is true even when you're caring for a patient with a fracture.

Tip: If you'll be providing multiple therapies, the correct code to list is V57.89 (Other specified rehabilitation procedure; multiple training or therapy), Adams says.

Following the V57.x code, you'll need to report a code to describe the condition being treated. This might be an aftercare for healing fracture code such as V54.1x (Aftercare for healing traumatic fracture) or V54.2x (Aftercare for healing pathological fracture) or it could be V54.81 (Aftercare following joint replacement) if the repair of the fracture is by a joint replacement or some other condition that requires therapy, or you may need to list a symptom code to indicate the focus of care for that patient.

On the other hand: When both nursing and therapy will be seeing a patient, there is no need for the V57.x code, Adams says. Instead, you'll most often list an aftercare of a healing traumatic or pathological fracture as the principal diagnosis, unless there is another more acute condition that will require more intensive skilled services, she says.

Coding scenario: Your patient was admitted after 3 weeks of rehab following a hip replacement due to a fracture after a fall at home. Physical therapy is ordered for gait and transfer training and strengthening. Occupational therapy will provide activities of daily living training. The patient has hypertension which is controlled with medication. Code for this patient as follows, Adams says.

• M1020a: V57.89 (Other specified rehabilitation procedure; multiple training or therapy);
• M1022b: V54.81 (Aftercare following joint replacement); M1024: 820.8 (Fracture of neck of femur: unspecified part of neck of femur, closed);
• M1022c: 401.9 (Essential hypertension; unspecified);
• M1022d: V43.64 (Joint replaced by other means; hip).

Multiple therapy disciplines will be seeing this patient, but no skilled nursing has been ordered, so V57.89 isyour principle diagnosis.

Follow this with V54.81 to indicate that therapy is providing aftercare for this patient's joint replacement. In situations like this, list V54.81, rather than a fracture aftercare code, because the patient's fracture has been treated with the joint replacement and the fracture is no longer present, says Joan L. Usher, BS, RHIA, COS-C, ACE, with JLU Health Record Systems in Pembroke, Mass.

Pair the joint replacement aftercare code with 820.8 inM1024 to indicate that a V code (V54.81) has replaced a case mix diagnosis code in M1022.

Next, list 401.9 to indicate that your patient has hypertension, but be certain that your documentation indicates how this condition will impact the care you provide.

Finally, list V43.64 to specify the location of your patient's joint replacement.

A fracture, like other medical conditions, can also have complications or late effects, Adams says. For example, a complication could be a periprosthetic fracture (996.44).

Late effects of a fracture include a non-union (733.82) or a malunion (733.81) of a fracture. These late effects require you to list an additional code to indicate that the condition is a late effect of a fracture. Look to the 905.x (Late effects of musculoskeletal and connective tissue injuries) codes for selections such 905.4 (Late effect of fracture of lower extremities) which clarify that a condition is a late effect of a fracture and specify the site of the break, Adams says. To sequence these codes correctly, follow the general rule for coding late effects: code the residual or condition produced first, followed by the late effect code, 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.

Caution: If your patient's fracture has been treated by a joint replacement and there are resulting complications, it's not appropriate to list a non-union of fracture code, Usher says.

When does a condition become a late effect of a fracture? There is no set timeframe that makes a condition a late effect. The patient must have had an acute fracture at some point in the past, Usher says. The condition could then be coded as a late effect after that fracture has resolved.

Complications and late effects can be treated medically with therapy services to improve function or may require surgical intervention to correct the problem, Adams says. When there is a surgical intervention that results in a clean surgical wound, the patient may return to home health to receive routine aftercare of a healing fracture, she says.