Home Health ICD-9/ICD-10 Alert

Question: Our patient was admitted for home care following an open reduction with internal fixation (ORIF) for a hip fracture after falling at home. He also has cystitis due to a Foley catheter that is still in place for urinary retention. Nursing will provide post-op and genitourinary assessment, teaching, and staple removal. Physical therapy will provide gait training.

Colorado Subscriber

Answer: List the following codes for this patient:

In your patient’s case, the primary focus of care for both nursing and therapy is aftercare for the healing traumatic hip fracture. So V54.13 is your primary diagnosis.

Follow this with a code to identify the infection, 595.9 for cystitis, in this case. Don’t make the mistake of listing 996.64 (Infection due to indwelling urinary catheter) for this patient. The code 996.64 is no longer used when a patient with a urinary catheter has a UTI, unless the physician specifically documents that the UTI is related to the catheter.

Also, list 788.20 for your patient’s urinary retention (because it is not resolved) and V58.32 to indicate the staple removal.

You may also want to add the E code for the fall at home (E849.0). This is optional but may help if there is any question of liability.

Mistake: Do not code V53.6 (Fitting and adjustment of urinary catheter). Your patient’s infection makes this a urinary complication, so you wouldn’t report a routine care V code.

Because the V code listed in M1020 replaces case mix diagnosis 820.8, you can list 820.8 in M1024. But because the patient does not have a pressure ulcer or infusion therapy you won’t earn any case mix points for the fracture in this scenario.