Home Health ICD-9/ICD-10 Alert

Say goodbye to one of home care’s most popular code categories.

Remember the rumor that made the rounds about aftercare coding becoming a thing of the past once the ICD-10 code set is adopted? By now, you probably know it was an exaggeration. But do you know exactly what you’ll be facing when it comes time to report subsequent care for a fractured hip repaired by a joint replacement or for aftercare of a hip replacement due to a medical condition such as osteoarthritis? Our experts give you a sneak peek at the new face of coding for aftercare.

Know these Aftercare Guidelines

In ICD-10, aftercare codes are used “when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease,” according to the ICD-10-CM Draft Official Guidelines for Coding and Reporting.

“The aftercare Z code should not be used if treatment is directed at a current, acute disease,” the guidelines say. “The diagnosis code is to be used in these cases.”

The aftercare Z codes should also not be used for aftercare for injuries, says Ann Zeisset, RHIT, CCS, CCS-P, AHIMA-Approved ICD-10-CM/PCS Trainer with Ann Zeisset Consulting in Trenton, Ill. For aftercare of an injury, assign the acute injury code with the appropriate seventh character (for subsequent encounter).

Farewell to Aftercare for Fractures

After Oct.1, 2014, you’ll no longer list an aftercare code when you are providing care related to a healing traumatic injury or fracture. Instead of listing V54.16 (Aftercare for healing traumatic fracture of lower leg), you’ll list a code such as S82.441D (Displaced spiral fracture of shaft of right fibula; subsequent encounter for fracture with routine healing).

This is a big change for home health coders. Since home health agencies provide aftercare rather than treating the acute injury, coders are used to listing aftercare codes for patients with fractures.

But under ICD-10, you’ll code for the injury with the appropriate seventh character instead, says Zeisset.

Tip: You’ll code for the fracture and not aftercare even when your patient has a healing pathological fracture.

ICD-10 Coding Guidelines advise coders not to use aftercare Z codes for conditions such as injuries or poisonings. Instead, the acute codes for these conditions offer seventh character options that indicate the patient is receiving subsequent care.

Heed this therapy coding change: Oft-listed therapy code V57.x (Care involving use of rehabilitation procedures) has no equivalent in ICD-10. Just as with fracture aftercare, there is no category for care involving rehabilitation in ICD-10, Zeisset says. Instead, you’ll list the code that best represents the diagnosis, condition, or problem that requires therapy if it is still present. If not, then an aftercare code is appropriate as long as it is not an injury. If an injury is involved, then you’ll report the injury code with the subsequent encounter seventh character.

Joint Replacements May Still Receive Aftercare in certain Circumstances

When your patient has had a joint replacement for a medical condition such as osteoarthritis, you will look to the aftercare Z codes to describe your care. For example, suppose your patient was referred for physical therapy and occupational therapy including gait training to address his abnormal gait following a hip replacement because of osteoarthritis of the right hip that was repaired by a joint replacement. He also has coronary artery disease (CAD) of native vessels with angina, stage 4 chronic kidney disease, and hypertension.

Code for this patient as follows, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates and CoDR — Coding Done Right in Denton, Texas:

• M1021a: Z47.1 (Aftercare following joint replacement therapy);
• M1023b: R26.9 (Unspecified abnormalities of gait and mobility);
• M1023c: I12.9 (Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease);
• M1023d: N18.4 (Chronic kidney disease, stage 4 [severe]);
• M1023e: I25.119 (Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris);
• M1023f: Z96.641 (Presence of right artificial hip joint).

Since the arthritis is no longer present, you’ll list an aftercare code for this joint replacement scenario. Follow that with R26.9 to further specify that your therapists will be addressing the patient’s gait abnormality.

Follow this with codes to specify your patient’s pertinent co-morbidities, and lastly include the status Z code that specifies which joint your patient had replaced.

Contrast this with the patient that has a joint replacement because of a fractured right hip (right subtrochanteric hip fracture) and is receiving physical therapy for a normal healing fracture, suggests Zeisset. For this patient, you would list S72.21XD (Displaced subtrochanteric fracture of right femur; subsequent encounter for closed fracture with routine healing) in M1021a.

The official ICD-10-CM coding guidelines state that aftercare codes should not be used for aftercare of traumatic fractures, Zeisset reminds. For aftercare of traumatic fractures, assign the acute fracture code with the appropriate seventh character.

Sequencing: While aftercare Z codes are generally listed as a primary diagnosis, they can also be used as secondary diagnoses when some other condition better explains the reason for an encounter.

For example: Suppose you’re providing aftercare for a patient following a hip joint replacement, but the wound has become infected and you will be providing both aftercare and wound care, including dressing changes. In this case, you’ll lead with a code to describe the infection — T81.4XXD (Infection following a procedure) but you’ll follow with Z47.1 (Aftercare following joint replacement therapy), or the fracture code depending on why the joint was replaced.

Multiples: You can list more than one aftercare code when it is appropriate to describe your patient’s condition.

Tip: Although they don’t say “aftercare” in the code titles themselves, Z48.-- (Encounter for other postprocedural aftercare) category codes change or removal of dressings and drains, and encouters for surgical aftercare following specified surgery fall into the aftercare category.

For example: Your patient had a cholecystectomy due to acute cholecystitis, and you will be providing aftercare and dressing changes. You would list both Z48.815 (Encounter for surgical aftercare following surgery on the digestive system) and Z48.01 (Encounter for change or removal of surgical wound dressing). 

Status: You may also list status Z codes to further specify an aftercare patient’s diagnoses.

Coding example: Your patient had a cholecystectomy due to acute cholecystitis. She also has a history of breast cancer and is taking Tamoxifen prophylactically. She’s had some problems with urinary retention after surgery. Orders are to DC the indwelling catheter and attempt to instruct on intermittent cath. Code for this patient as follows, says Selman-Holman:

• M1021a: Z48.815 (Encounter for surgical aftercare following surgery on the digestive system);
• M1023b: R33.9 (Retention of urine, unspecified);
• M1023c: Z46.6 (Encounter for fitting and adjustment of urinary device);
• M1023d: Z79.810 (Long term [current] use of selective estrogen receptor modulators [SERMs)); and
• M1023e: Z85.3 (Personal history of malignant neoplasm of breast).