Home Health ICD-9/ICD-10 Alert

Know when not to report abnormality of gait.

Coding for traumatic brain injuries can leave your head spinning. Do you know whether to use an intracranial injury code or if you should report aftercare instead? And how do you know when you're dealing with late effects?

For more on this heady topic, see "Solve Your Traumatic Brain Injury Coding Headaches" in the March 2006 Home Health ICD-9 Alert. 

Scenario 1: The patient is admitted to home care after being discharged from the hospital following craniotomy and evacuation of cerebral hemorrhage. The injury resulted from a fall from a ladder at home.

The patient's diagnosis is traumatic cerebral hemorrhage with brief loss of consciousness and open wound to the forehead. An X-ray showed no fracture. 

The patient is experiencing cognitive deficits and requires a skilled nurse to assess and monitor his condition and to provide wound care for the head wound. A physical therapist will work with him to regain his mobility, and provide gait training and safety measures.

Scenario 2: A 43-year-old male patient admitted to the hospital three weeks before is referred for home care nursing and therapy services (PT and OT). The patient, who works for a logging company, had been struck in the head by a falling tree limb and sustained a left temporal skull fracture with a large subdural hematoma that required surgical intervention. 

The patient arrived at the emergency room approximately two hours after the accident due to the isolated area in which the trauma occurred. He remained unconscious from the time of the accident through post-op recovery.

During the post-op period, the patient has been confused and displays right-sided weakness to both arm and leg (patient is right side dominant). MRI confirms infarcted areas to the left temporal lobe of the brain which neurology believes was caused by pressure from the hematoma. One week post-op, the anterior end of the patient's incision separated, creating a 6 cm by 1.5 cm wound that has been infection free but continues to drain moderate amounts of serous drainage.
 
Home care therapy services (physical therapy and occupational therapy) are each visiting three times a week for gait training and self care deficits. Nursing is visiting two times a week for neurological checks and wound care. 

How to do it: Have you decided how you would code for these scenarios? Read on to see how our experts reported these patients.

Scenario 1: Code for this patient as follows, suggests Dio Namocatcat, CCS, HCS-D, CPC with the Visiting Nurse Regional Health Care System in Brooklyn, NY:

• M0230a: V58.43 (Aftercare following surgery for injury and trauma);
• M0240b: 873.42 (Other open wound of head, face, without mention of complication, forehead);
• M0240c. V58.3 (Attention to surgical dressings and sutures);
• M0240d: 310.2 (Posttraumatic brain syndrome, nonpsychotic);
• M0240e: 907.0 (Late effect of intracranial injury without mention of skull fracture);
• M0240f: 781.2 (Abnormality of gait); and
• M0245a: 853.02 (Traumatic cerebral hemorrhage with brief loss of consciousness).

Because you are reporting a V code in M0230a, you'll need to place the case-mix code in M0245a, says Namocatcat. Report an aftercare code like V58.43 when the initial treatment of a disease or injury is completed but the patient requires continued care during the recovery phase, he says.

Code 310.2 is appropriate for this type of memory lapse or memory loss related to traumatic brain injuries, Namocatcat explains. Follow this with the late effect of injuries code from series 905-909 (Late effects of injuries, poisonings, toxic effects, and other external causes).

Be careful: Don't use code 438.0 (Late effects of cerebrovascular disease, cognitive deficits) with traumatic injuries to the brain. You could also include the optional E code E881.0 (Fall from ladder).

Scenario 2: Keith Nielsen, RN, HCS-D, PPS/OASIS coordinator with Great Lakes Home Healthcare in Erie, PA says he would report the following for this patient:

• M0230a: V54.19 (Aftercare for healing traumatic fracture of other bone);
• M0240b: 342.91 (Hemiplegia, unspecified, affecting dominant side);
• M0240c: 998.32 (Disruption of external operation wound);
• M0240d: 293.0 (Delirium due to conditions classified elsewhere); and
• M0240e: E916 (Struck accidentally by falling object).

Because this is a 43-year-old patient, Medicare isn't involved in the scenario, says Lisa Selman-Holman, JD, BSN, RN, CHCE, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX. So, you wouldn't report a code in M0245. If hemiplegia were the focus of the care, you would code the hemiplegia first, then 905.0 (Late effect of fracture of skull and face bones), she suggests. For a Medicare patient, you would gain 20 points for reporting hemiplegia in M0230, she notes.

Because there are no specific aftercare codes for head injuries and trauma fracture codes aren't appropriate for home care, code for the conditions resulting from the trauma, advises Nielsen.

Don't code: You might be tempted to include 781.2 (Abnormality of gait), but Nielsen points out this condition is part of hemiplegia and shouldn't be coded separately. Also leave off V58.3 (Attention to surgical dressings and sutures), he says. You've already coded a wound complication with 998.32, so wound care is assumed, he explains.