Home Health ICD-9/ICD-10 Alert

Published on Sun Nov 20, 2011 PDF

Question: Our new patient has the following diagnoses: lumbosacral spondylosis, lumbar spinal stenosis, difficulty ambulating, weakness, osteoarthritis, and peripheral neuropathy. He also has a history of recent falls. We are providing physical therapy only for strength training, gait training, and to improve safety. The patient needs reminding to use his walker for gait stability. He is at high risk for falling. How should we code for him?

South Carolina Subscriber

Answer: For this patient, you would list the following codes:

• M1020a: V57.1 (Care involving other physical therapy);
• M1022b: 721.3 (Lumbosacral spondylosis without myelopathy);
• M1022c: 724.02 (Spinal stenosis; lumbar region, without neurogenic claudication);
• M1022d: 356.9 (Hereditary and idiopathic peripheral neuropathy; unspecified);
• M1022e: 715.90 (Osteoarthrosis, unspecified whether generalized or localized; site unspecified); and
• M1022f: V15.88 (History of fall).

List V57.1 first because this is a therapy-only case. Follow this with the condition physical therapy is caring for, in this scenario, lumbosacral spondylosis and lumbar spinal stenosis.

The next code -- for your patient's peripheral neuropathy -- includes weakness as a symptom, so there's no need to code weakness separately. Never list a symptom code when you have a definitive diagnosis.

Next, list 715.90 for osteoarthrosis. Fifth digit "0" indicates that the affected joint isn't identified. Try to be more specific for the sites of the osteoarthrosis. If multiple joints were affected, you would use 715.89 (Osteoarthrosis involving, or with mention of more than one site, but not specified as generalized).

Finally, list V15.88 to indicate that your patient has a history of falls and is at risk of falling again.