Home Health ICD-9/ICD-10 Alert

Earn your agency the maximum available points by perfecting your V55.x sequencing.

For the first time, PPS includes V codes in the case mix diagnosis list. But these three category V55.x (Attention to artificial openings) codes aren't appropriate for every patient with an ostomy. Make sure you know when it's right to report these codes to be certain your agency secures the reimbursement you deserve.

This is the first time agencies are seeing V codes on the case mix list, and we may see more in future changes, says Judy Adams, RN, BSN, HCS-D, with LarsonAllen in Charlotte, NC.

The three V codes are V55.0 (Tracheostomy), V55.5 (Cystosto-my) (also used for suprapubic catheters), and V55.6 (Other artificial opening of urinary tract), which includes attention to openings such as nephrostomy, ureterostomy, and urethrostomy.

Congratulations: These case mix V codes are a result of home care folks pointing out the costs of dealing with patients who have ostomies, Adams says. That's another reason to send comments back to the Centers for Medicare & Medicaid (CMS) whenever a proposed rule gives you the opportunity, she says.

Report codes from the V55.x category only if your agency is providing skilled care for the catheter, says Jun Mapili, PT, MAEd, with Global Home Care in Troy, MI. These codes are intended to report adjustment or repositioning of a catheter, closure, passage of sounds or bougies, reforming, removal or replacement of a catheter, toilet or cleansing. Otherwise, it's not appropriate to list a V55 code.

When there's no need for care, such as when the patient or caregiver cares for the ostomy, look to the V44.x category (Artificial opening status) to report the presence of a catheter.

Important: The three V55.x "attention" codes are case mix diagnoses and the V44 "status" codes are not, says Mapili. You're upcoding if you use any of the three case mix V55.x codes when you're not providing related care, he says.

Example: You're coding for a therapy-only case for a patient who has a cystostomy. Your agency isn't providing any associated care to the ostomy, so you should report its presence with status V code V44.5x (Cystostomy).

Don't list a V55.x code when your patient's artificial opening has a complication such as an infection, Mapili says. For example, you'll notice that "complications of external stoma" is listed as an exclusion in the V55.x entry of your ICD-9 manual.

Instead, look to complication codes such as 519.00-519.09 (Tracheostomy complications) and 996.64 (Infection and inflammation due to the presence of indwelling urinary catheter) or 997.5 (Urinary complications) for reporting complications of tracheostomies and urostomies.

Take note that the complication codes for colostomies, 569.60-569.69 (Colostomy and enterostomy complications), and gastrostomies (536.4x, Complications of gastrostomies) are case mix codes. The V codes for such ostomies are not case mix codes, but often coders mistakenly use the V code even when the colostomy or gastrostomy is complicated.

If the area around the ostomy is denuded, there is cellulitis involved, or there is some other complication, then use the complication code. The complication codes earn points from the gastrointestinal diagnostic category.

Example: The patient's gastrostomy is surrounded by cellulitis. You should report:

• M0230a: 536.41 (Infection of gastrostomy) (case mix GI) and

• M0240b: 682.2 (Other cellulitis and abscess; trunk) (case mix Skin 2).

You'll also need to look elsewhere when you're caring for temporary artificial openings such as chest tubes, Mapili says.

Make Best Use Of M0230, M0240

If listing a V55.x code is appropriate for your patient, be sure to list it in the first six OASIS diagnosis code slots so your agency receives the correct reimbursement. In order to garner points, you must list the case mix code in M0230 or M0240, Mapili says. Failure to appropriately sequence the diagnosis will result in lower reimbursement, he says.

For instance: Your new patient has hypertension (severity of 3) with blood pressure of 190/115. He also has congestive heart failure (CHF) with peripheral edema (severity of 2), type 2 diabetes (severity of 2) with peripheral angiopathy (severity of 2) and current insulin use. He also needs replacement and teaching of suprapubic catheter (severity of 2), and osteoarthritis (severity of 2).

The chief reason for admission is hypertension, so you should list 401.9 (Essential hypertension; unspecified), in M0230, Mapili says. Follow this with 428.0 (Congestive heart failure, unspecified), 250.70 (Diabetes with peripheral circulatory disorders; type II or unspecified type, not stated as uncontrolled), 443.81 (Peripheral angiopathy in diseases classified elsewhere), and 715.9x (Osteoarthrosis, unspecified whether generalized or localized).

This leaves you with one empty slot in M0240 but two potential V codes to fill it. Because V55.5 requires skilled nursing, code for it first and place V58.67 (Long-term [current] use of insulin) in field locator 21 -- the orders box on the Plan of Care.

Golden rule: Always prioritize the diagnoses that need the skilled service, Mapili says.

Problem: V codes like V49.84 (Bed confinement status), V45.01 (Cardiac device in situ; cardiac pacemaker) and V46.2 (Other dependence on ma-chines; supplemental oxygen) are great for painting a good picture of your patient's condition. But listing them in the first six diagnosis code spots at the expense of other important co-morbidities will negatively impact statistics, not to mention your bottom line, Mapili says.

Solution: List status V codes after pertinent co-morbidities like CHF and diabetes.

Tip: Don't waste space by over-coding. Coding guidelines advise not to code conditions (or symptoms) that are an integral part of a disease. For example, don't list a separate code for edema caused by CHF. The edema is integral to the CHF, so this code would take up a valuable spot where you could otherwise list another more pertinent diagnosis code. This could mean losing reimbursement if the bumped diagnoses are case mix, Mapili says.

You would gain case mix points for the following diagnoses in this scenario: essential hypertension, diabetes and attention to the cystostomy.

See the article below for a breakdown of the points you can earn with the new case mix V codes.