Home Health ICD-9/ICD-10 Alert

Question: Our new patient has returned home after suffering several falls and sustaining bilateral subdural hematomas for which she had an evacuation. She has vertigo, atrial fibrillation, and hypertension. We will be providing skilled nursing and physical therapy. How should I code for her?

Virginia Subscriber

Answer: Code for this patient as follows:

In this case, the V code V58.43 replaces the case mix diagnosis 852.20. Your patient's hematoma was evacuated, so she no longer has it, but you can still place the code for the hematoma in M1024 for additional case mix points

Follow V54.83 with 780.4 to indicate that your patient also has vertigo. If the documentation indicates that the patient's head injury caused the vertigo, list 907.0 (Late effect of intracranial injury without skull fracture) as the next code. Then add 427.31 to report her atrial fibrillation.

Next, list 401.9 to indicate that your patient also has hypertension. If you can determine whether the hypertension is malignant or benign, you can use the appropriate, more specific code.

You may include the optional E code E888.9 to show that she fell. If you can learn more about the falls, you should use a more specific code.

Check the notes: You might be tempted to use V58.72 (Aftercare following surgery of the nervous system, NEC) or even V58.73 (Aftercare following surgery of the circulatory system, NEC) the code normally used for a CVA resulting from a bleed, instead of V58.43. However, you should stick with V58.43 because the patient is receiving aftercare of a traumatic injury, which covers conditions classifiable to 800-999. Code V58.72, on the other hand, is for conditions classifiable to 320-359 and V58.73 is for conditions classifiable to 390-459.

Classifying intracerebral bleeds can be confusing. Remember that the subdural hematoma from hitting the head is a traumatic head injury, whereas the subdural hematoma from a blood vessel spontaneously rupturing is a cerebrovascular accident. Here's an easy way to remember the difference: external injury = traumatic while internal injury = CVA.