Home Health ICD-9/ICD-10 Alert

Code 996.4 now requires a fifth digit.

If you're still coding chronic kidney disease with 585 on a new plan of care, watch out: New and changed codes for kidney disease, diabetic retinopathy and orthopedic devices went into effect on Oct. 1, and if your agency isn't prepared, you may already have claims at risk.

Note Stages for Chronic Kidney Disease 

When coding chronic kidney disease, be sure to keep your new or updated coding manual close at hand. The old code for chronic kidney disease (585) has changed to require a fourth digit, so 585 is no longer a valid code. Instead, use one of these seven new and more specific codes:

• 585.1 (Chronic kidney disease, Stage I)
• 585.2 (Chronic kidney disease, Stage II [mild])
• 585.3 (Chronic kidney disease, Stage III [moderate])
• 585.4 (Chronic kidney disease, Stage IV [severe])
• 585.5 (Chronic kidney disease, Stage V)
• 585.6 (End stage renal disease)
• 585.9 (Chronic kidney disease, unspecified).

With these seven new codes, you can code the stage or severity of the kidney disease, says Lynn Yetman, RN, MA, HCS-D, COS-C, LNC, with Reingruber & Company in St. Petersburg, FL. Previously called chronic renal failure, the change to chronic kidney disease makes these codes more precise, experts say.
 
Use codes 585.1 through 585.5 for chronic kidney disease stages I through V. (See the Glomerular Filtration Rate chart later in this issue for help in choosing the appropriate code based on the lab data for your patient.) 

You should use code 585.6 for end stage renal disease and 585.9 for documented chronic renal insufficiency or unspecified chronic kidney disease.

Tip: Patients with end stage renal disease will likely be either on dialysis or in the transplant process, so you should follow 585.6 with a V code to record their status, notes Yetman. Remember to use V codes to indicate specific aftercare for a resolving disease, injury or chronic condition or to report special therapy, organ donation status, prophylactic care or counseling.
  
Use V42.0 (Organ or tissue replaced by transplant, kidney) for a patient who has received a kidney transplant, V45.1 (Renal dialysis status) for patients receiving dialysis, or V49.83 (Awaiting organ transplant status) for patients awaiting organ transplant. 

The new chronic kidney disease codes will also be noted as manifestations under 250.4x (Diabetes with renal manifestations). When chronic kidney disease is the result of diabetes, you can use one of these new codes to specify the stage or severity.

Look for Retinopathy Progression

The new codes for diabetic retinopathy allow you to specify whether the patient's disease is nonproliferative, mild, moderate or severe:
 
• 362.03 (Nonproliferative diabetic retinopathy NOS)

• 362.04 (Mild nonproliferative diabetic retinopathy)

• 362.05 (Moderate nonproliferative diabetic retinopathy)

• 362.06 (Severe nonproliferative diabetic retinopathy)

• 362.07 (Diabetic macular edema)

These additional five-digit codes, which show the progression of diabetic retinopathy, are likely to be used in home health because of the high number of diabetics agencies care for, senior clinical consultant Judy Adams, RN, BSN, HCS-D, with Charlotte, NC-based LarsonAllen Health Care Group, told listeners during the Sept. 22 Eli Research teleconference "2006 ICD-9 Coding Update for Home Health."

Remember: Check the patient record to be certain the link between diabetes and retinopathy is established before assigning these codes.

Example: For a patient with diabetic retinopathy, you would first report 250.5x (Diabetes with ophthalmic manifestations), and then code the corresponding 362.0x (Diabetic retinopathy) code for the type of retinopathy. If the patient has macular edema, follow the retinopathy code with 362.07.

Use a Fifth Digit for Implant Complication

Get ready to change your implant or device complication coding. Code 996.4x (Mechanical complication of internal orthopedic device, implant, and graft) now requires a fifth digit, says Yetman.

The following nine new codes describe common complications of surgical joint replacements. These complications can include dislocation, fracture and instability, but exclude complications of external orthopedic devices such as a pressure ulcer due to a cast, explains Yetman.

• 996.40 (Unspecified mechanical complication of internal orthopedic device, implant, and graft)

• 996.41 (Mechanical loosening of prosthetic joint)

• 996.42 (Dislocation of prosthetic joint)

• 996.43 (Prosthetic joint implant failure)

• 996.44 (Peri-prosthetic fracture around prosthetic joint)

• 996.45 (Peri-prosthetic osteolysis)

• 996.46 (Articular bearing surface wear of prosthetic joint)

• 996.47 (Other mechanical complication of prosthetic joint implant)

• 996.49 (Other mechanical complication of other internal orthopedic device, implant, and graft).

Tip: Don't forget to add the V code (V43.60-V43.69) to indicate which joint is involved, Adams notes. For instance, a patient who has difficulty with his hip replacement and is diagnosed with dislocation would be coded as 996.42 (Dislocation of prosthetic joint), followed by V43.64 (Organ or tissue replaced by other means, hip) to indicate that the hip joint is involved.

Don't miss: Code 996.66 (Infection and inflammatory reaction due to internal prosthetic device, implant and graft, due to internal joint prosthesis) now requires you to report the appropriate V code (V43.60-V43.69) as well.  For example, a patient with an inflammation complication to his hip prosthesis caused by Staph aureus would be coded 996.66, 041.11 (Staphylococcus aureus) and V43.64. 

When answering OASIS, since M0190 does not allow V codes, you should report the V code to identify the joint only in M0230 or M0240. 

Example: If your agency sees a patient with hip joint complications after the hip has been revised, you would report the complication code in M0190. Then, you would  report V54.81 (Aftercare following joint replacement) in M0230 or in M0240 if the revision was successful, along with the appropriate V43.6x code to indicate the joint replaced.

Indicate ST Elevation With New 410 Series Notes

There are no new codes in the 410.x (Acute myocardial infarction) series, but new descriptors have been added to make them more precise. 

Now the 410.x series codes include notes about ST elevation. You should use a fourth digit with these codes to identify the area of infarction, if known. Home health agencies will use 410.x2 if home health services are ordered within eight weeks after the MI, says Yetman.

Watch For History of Falls V Codes

Several of the new V codes that may be useful in home health are V15.88 (History of fall), V12.61 (Personal history, Pneumonia [recurrent]) for either recent or repeated episodes of pneumonia, and V49.84 (Bed confinement status), Adams predicts. 

Some of these new V codes, such as V15.88 and V64.0x (Vaccination not carried out) relate back to national patient safety goals from the Joint Commission on Accreditation of Healthcare Organizations and will help agencies identify and track the types of patients that impact safety goal outcomes, says Ida Blevins, RHIA with St. John's Hospital Home Health Services in Springfield, IL.