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Home Health ICD-9/ICD-10 Alert

Conquering Case Mix:

Spot Check Your CAD Coding or Risk Case Mix Points

Published on Tue May 15, 2012

Keep track of CABG status to find the right CAD code.

Most codes in the 414.x (Other forms of chronic ischemic heart disease) category offer case mix points. But if you don't know which code to use and when to use it, your coding could have a negative impact on your company's bottom line.

Know These Home Health CAD Coding Workhorses

There are two coronary artery disease codes that home health coders use frequently, says Sharon Molinari, RN, HCS-D, HCS-O, a home health consultant based in Henderson, Nev.

The default code for your patients with CAD is 414.00 -- Coronary atherosclerosis of unspecified type of vessel, native or graft. When the documentation does not identify the coronary artery involved, 414.00 is your code, says Joan L. Usher, BS, RHIA, COS-C, ACE, president, of JLU Health Record Systems in Pembroke, Mass.

When the documentation indicates that your patient's CAD is in a native coronary artery or if there is no history of a previous coronary artery bypass graft (CABG), list 414.01 -- Coronary atherosclerosis of native coronary artery, says Usher.

ICD-9 code 414.01 isn't appropriate for patients who have had a CABG because there is the potential that the CAD affects a bypass graft artery. Without documented details as to which vessel is affected, look to 414.00 for patients who have had a CABG, Molinari says.

Caution: While 414.05 -- Coronary atherosclerosis of unspecified bypass graft might appear to be the right code to list for a patient with CAD who has had a CABG, it's probably not your code. This code describes CAD of the bypass graft itself, not CAD in a patient who just had a CABG, Molinari says.

In home health, you aren't likely to get the details needed to list a code like 414.05, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas. So you're more likely to list 414.00 for these patients.

Avoid unspecified codes: The only code in the 414.x category that isn't a case-mix code is 414.9 -- Chronic ischemic heart disease, unspecified.

Should You List CAD in M1024?

When your patient is receiving aftercare following a CABG for CAD, and there are no complications, you'll list V58.73 (Aftercare following surgery of the circulatory system, NEC) in M1020a, Molinari says. But the CAD still exists following the CABG, so should you list a CAD code in M1024?

The best process for deciding whether to list the CAD code in M1024 is to consider whether CAD meets one of the criteria for this item:

1) Is the V code as primary replacing a case mix diagnosis that earns more points when primary?

2) Is the V code replacing a resolved case mix diagnosis?

3) Is the V code replacing a fracture?

"In all 3 cases, the answer is no, so the 414.x code does not belong in M1024," Selman-Holman says.

Make sure to include the codes for any other pertinent comorbidities and V45.81 (Post-surgical aortocoronary bypass status), Molinari says. Many surgeries use the V58.73 aftercare code, but including V45.81 "really nails the CABG as the surgery." Because V code sequencing is discretionary, you can list this code after the numeric codes when your patient has multiple comorbidities.

Tip: When completing OASIS items M1010 (Inpatient Diagnoses) and M1016 (Diagnoses Requiring a Change in Treatment) for this patient, you would list 414.01 in M1010 because the patient hadn't had the CABG at that time, Molinari says. Remember to follow the specific instructions for these items.

Coding example: Your 81-year-old patient was admitted to the hospital with a new diagnosis of CAD. While there, she had a CABG x 3 using the saphenous vein. You will be providing skilled nursing to assess cardiac status, assess wound healing, teach family to perform dressing change to chest wound assess signs and symptoms of infection and teach disease process. Code for this patient as follows:

  • M1010: 414.01;
  • M1016: 414.01;
  • M1020a: V58.73;
  • M1020b: 414.00;
  • M1020c: V58.31 (Encounter for change or removal of surgical wound dressing); and
  • M1020d: V45.81.

Although you know that the patient had a CABG, the documentation doesn't indicate that the CAD is in the bypass graft, so your CAD code is 414.00.

Editor's note: This new column will feature coding tips for the most commonly reported home health diagnoses as determined by Seattle-based home care consultants OCS Homecare.

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