Home Health ICD-9/ICD-10 Alert

Question: We admitted an elderly patient after an open reduction for a fractured left ankle. Physical therapy will be the focus of home care, so we plan to use V57.1 as our primary diagnosis. What other codes do we use, and do we need to put a code in M0245?

Answer: Your primary diagnosis V57.1 (Other physical therapy) goes in M0230. This diagnosis displaces 781.2 (Abnormality of gait), which is still current and being treated. So you place the abnormality of gait code in M0240, followed by either V54.16 (Aftercare for healing traumatic fracture of lower leg) or V54.26 (Aftercare for healing pathological fracture of lower leg) depending on what caused the fracture. This code describes the underlying reason for the gait difficulty. Finally, you also put 781.2 in M0245, so you will receive the extra reimbursement you are owed.