Home Health ICD-9/ICD-10 Alert

How would you code this cancer scenario?

If you've got patients with multiple co-morbidities, ensure that you have full details on the acuity of each condition so you can code correctly and secure your deserved reimbursement.

Coding Scenario: Your patient has ovarian cancer and is receiving chemotherapy at the doctor's office. She also has interstitial lung disease, a urinary tract infection (UTI), a colostomy, osteoarthritis, an alteration in gait, and deep vein thrombosis in her lower extremities.

You are providing nursing twice a week for anti-coagulant therapy (Coumadin) and PT-INR (prothrombin time-international normalized ratio) tests and cardiopulmonary assessment for her lung disease. Physical therapy is making more frequent visits to assist with the alteration in gait. Your care isn't directed specifically at the cancer and you aren't providing the chemotherapy, but these are important aspects of your patient's overall health picture.

Look To Clinician For Acuity

First of all, the clinician will need to determine the acuity of each of these conditions related to the home health care plan, says clinical consultant Judy Adams, RN, BSN, HCS-D, with LarsonAllen in Charlotte, NC. Acuity ranking for medical conditions is neither the same as the severity rating for diagnoses nor dependent strictly on the number of visits being provided. Instead, it is a combination of both in the context of the home health plan of care.

Although there is no requirement to sequence the codes in order of the severity index, the Medicare Claims Processing Manual in Chapter 10 states: "In listing the diagnoses, the HHA places them in order to best reflect the seriousness of the patient's condition and to justify the disciplines and services provided in accordance with the Official ICD-9-CM Guidelines for Coding and Reporting."

Second, clinicians must collect adequate assessment information in order to code episodes correctly, Adams says. In the situation above, there are several unanswered questions or areas that require further clarification.

Get To The Bottom Of Gait Alteration

You wouldn't code alteration in gait (781.2) as a diagnosis in this situation, Adams says. More than likely, the therapist is saying that the patient has changes in her gait, but the therapist needs to provide additional information related to the cause of the patient's gait alteration.

For example: Is the gait alteration because the patient has muscle weakness or generalized weakness as a result of her ovarian cancer and the chemotherapy treatments? Or is she experiencing weakness because of breathing issues associated with the interstitial lung disease?

If the weakness is associated with the pulmonary disease, that condition would appear to be the most acute condition because both physical therapy and nursing are addressing aspects of the pulmonary disease, Adams says.

On the other hand, is the gait alteration a result of the osteoarthritis? If this is the case, where is the osteoarthritis located? Code 715.99 (Osteoarthrosis, unspecified whether generalized or localized; multiple sites) is not a case mix diagnosis, but more specific codes for osteoarthrosis that define specific locations are case mix codes. Only the fifth digits for hip and knee are included as case mix diagnoses.

Additionally, the gait issue related to the osteoarthritis could be addressed by simply coding the osteoarthritis, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX. In any case, abnormality of gait (781.2) is not the correct code. The correct code for this alteration in gait is 719.7 (Difficulty in walking).

Ask For Cancer, DVT Details

Is the ovarian cancer primary cancer or secondary cancer (metastasis)? Most ovarian cancers are primary (183.0); however, if you code the cancer as unspecified (239.5) rather than verifying with the physician, you'll lose an opportunity to accumulate case mix points.

Is the interstitial lung disease acute (136.3, Pneumocystosis) or chronic (515, Postinflammatory pulmonary fibrosis)?

Your patient receives chemotherapy at the physician's office, but does she have a central line or mediport that the home health staff or patient will have to flush with heparin and saline between treatments? If so, you should add V58.81 (Fitting and adjustment of vascular catheter) to the list of codes and mark infusion therapy in M0250 to reflect the heparin flushes in the home.

Is the DVT of the lower extremities a new onset and therefore an acute diagnosis with the blood clots still present in the lower extremity (453.40, Venous embolism and thrombosis of unspecified deep vessels of lower extremity)? Or has the initial phase passed and is the patient being treated with anticoagulants as a prophylactic measure for which you should use a history code (V12.51, Personal history of venous thrombosis and embolism)?

Why does the patient have a colostomy? What was the underlying diagnosis? Will the home health staff or the patient or caregiver provide the colostomy care? The correct V code depends on who is providing the care, Selman-Holman says. If the colostomy is complicated in any way -- by infection or otherwise -- then the V code is not appropriate and you should code for the complication to the colostomy instead.

Is the UTI current? A UTI associated with a urinary catheter is coded differently than a UTI not associated with a urinary catheter, says Selman-Holman. And if the UTI is resolved and the patient is at risk for further UTIs, you should use the code for personal history of UTI -- V13.02.

Coding Scenario: For the sake of example, assume that the interstitial lung disease is chronic. We'll also assume the cause of weakness and subsequent gait alterations are in conjunction with the ovarian cancer treatment. The patient has osteoarthritis in her lower leg.

You would code for this patient as follows, Adams says:

• M0230a: 515 (Postinflammatory pulmonary fibrosis);

• M0240b: 183.0 (Malignant neoplasm of ovary);

• M0240c: V12.51 (Personal history of venous thrombosis and embolism);

• M0240d: 715.96 (Osteoarthrosis, unspecified whether generalized or localized; lower leg);

• M0240e: 599.0 (Urinary tract infection, site not specified); and

• M0240f: V58.83 (Encounter for therapeutic drug monitoring).

Don't stop there: List these additional diagnoses on the plan of care: V58.61 (Long-term [current] use of anticoagulants) and V44.3 (Artificial opening status; colostomy) because there is no mention that home health will be attending to the colostomy. Also, document in the medical record that the patient is receiving chemotherapy at the physician's office.

Case mix tally: Sequencing the episode in this manner provides potentially one to two case mix diagnoses and four potential diagnoses that will be used in risk adjustment for outcomes.