Home Health ICD-9/ICD-10 Alert

Question:  Our patient was referred to home health for an acute exacerbation of her multiple sclerosis. She is experiencing increased gait problems and difficulty performing activities of daily living (ADL). She has new medication and nursing will be assessing her medication regimen, performing venipuncture for blood levels of the new drug. providing a neurological assessment, and performing catheter changes for her neurogenic bladder. She will also receive physical therapy and occupational therapy. How should we code for this patient?

Answer:  Code for this patient as follows:

• M1020a: 340 (Multiple sclerosis);
• M1022b: 596.54 (Neurogenic bladder NOS);
• M1022c:V58.83 (Encounter for therapeutic drug monitoring);
• M1022d: V58.69 (Long-term [current] use of other medications); and 
• M1022e: V53.6 (Fitting and adjustment of urinary devices).

You’re seeing this patient for an exacerbation of her MS, so you’ll report 340 as the principal diagnosis. 

The patient’s neurogenic bladder is the underlying cause of her catheter care needs, so you can list 596.54 next.

Finally, list your V codes: V58.83 for the medication monitoring, V58.69 to indicate that the patient is on long-term medication, and V53.6 to describe the catheter care.

Caution: Although your patient is experiencing gait problems, you shouldn’t include 781.2 (Abnormality of gait) because this is an integral symptom of her MS.

In ICD-10 for this patient, you would report:

• M1021a: G35 (Multiple sclerosis);
• M1023b: N31.9 (Neuromuscular dysfunction of bladder, unspecified);
• M1023c: Z51.81 (Encounter for therapeutic drug level monitoring);
• M1023d: Z79.899 (Other long-term [current] drug therapy); and
• M1023e: Z46.6 (Encounter for fitting and adjustment of urinary device).

Once again, your patient’s MS is the principal diagnosis. 

Follow this with N31.9 to report your patient’s neurogenic bladder. Don’t miss the instructional note that asks you to list an additional code in the N39.3-N39.4- range to identify any associated urinary incontinence if you have such details.

Finally, list three Z codes: Z51.81 to indicate that you are providing drug monitoring, Z79.899 to indicate that the patient is on long-term medication, and Z46.6 to describe the catheter care.