Home Health ICD-9/ICD-10 Alert

Utah Subscriber

Answer: Code for this patient as follows:

• M1020a: V58.43 (Aftercare following surgery for injury and trauma);
• M1022b: 704.00 (Alopecia, unspecified);
• M1022c: 906.5 (Late effect of burn of eye, face, head, and neck);
• M1022d: V58.31 (Encounter for change or removal of surgical wound dressing); and
• M1022e: V58.62 (Long-term [current] use of antibiotics).

Look to the ICD-9-CM Official Guidelines for Coding and Reporting for specific guidance on coding burns.

The surgery was directed at the late effects of your patient's burns, so you'll need to code for them next. List 704.00 (Alopecia, unspecified) first to follow late effects sequencing guidelines. This late effect residual condition was treated by the surgical intervention but remains unresolved. Next list the late effect code 906.5 (Late effect of burn of eye, face, head, and neck).

Tip: To locate a late effect code, look for the main term "late" in the alphabetic index. Late effect codes for burns have further differentiation depending on the location of the burn.

Next, list V58.31 (Encounter for change or removal of surgical wound dressing).

Finally, list V58.62 (Long-term [current] use of antibiotics) to report the prophylactic use of antibiotics. The guidelines for V58.6 state that this subcategory indicates a patient's continuous use of a prescribed drug for long-term treatment of a condition or for prophylactic use.

You won't list a code in M1024 because the underlying diagnosis that has been resolved, the contracture (729.90), is not a case mix code. Instead, list it in M1010 (Inpatient Diagnoses) and M1016 (Diagnoses Requiring Medical or Treatment Regimen Change Within Past 14 Days) if the condition was treated in the last 14 days.