Home Health ICD-9/ICD-10 Alert

Question: Our 80-year-old patient went to the hospital for help with abdominal pain. She was diagnosed with gastritis. While in the hospital, she was found to have a fecal impaction and a urinary tract infection (UTI). We are providing physical therapy and occupational therapy for gait difficulty and lack of coordination. She still has abdominal pain and low albumin levels for which she will need a repeat lab in one month. She has a history of uterine and colon cancers and has also been diagnosed with arrhythmia. How should I code for her?


Delaware Subscriber

Answer: Your coding depends on the prioritization of your care and which of the conditions still exist. For example, your patient most likely doesn't have a fecal impaction anymore, so you wouldn't code for that. If she no longer has a UTI, you shouldn't code for this as a current condition either, although you may report a history of UTI with V13.02.

Gastritis may be acute or chronic, so you need to query the physician regarding her continuing abdominal pain. Is it due to the gastritis, which may be chronic, or an aftermath of the neoplasms?

Low albumin is not integral to any other condition named, so ask the physician why the patient has low albumin.

Tip: Sequence the gastritis or abdominal pain, the lack of coordination (781.3), low albumin levels and arrhythmia in order of severity and according to the prioritization of your plan of care. Add V codes for history of UTI (V13.02), history of uterine cancer (V10.41) and history of colon cancer (V10.05).