Home Health ICD-9/ICD-10 Alert

Question: Is it appropriate to report a code for gait abnormality when we are providing aftercare following a hip joint replacement?

Answer: Yes, you can report symptom codes along with aftercare V codes when they provide additional specifics about the problem your care is addressing.

The American Hospital Association's Coding Clinic for ICD-9-CM discussed this issue in the first quarter 2011, suggesting that you could list 781.2 (Abnormality of gait) in conjunction with V54.81 (Aftercare following joint replacement).

There is some debate among home care coding experts about whether or not to list the abnormality of gait code when providing aftercare for surgeries to the lower extremities. Coding Clinic says 781.2 may be assigned in conjunction with V54.81, and there are those who interpret this wording as a permissive instruction and not a requirement. These experts believe that abnormality of gait is inherent in V54.81 and the V43.6x (Joint replacement) codes for lower extremities.

Another example: Suppose your patient had a discectomy to correct a herniated disc. Nursing is providing post-surgical care, and therapy is addressing his weakness and numbness in his left leg.

For this patient, you could list:

Bonus: Your patient's herniated disc has been resolved by the surgery, so you can't list the code for it in M1020 or M1022, but you can still list 722.2 in M1024 to gain case mix points.