Home Health ICD-9/ICD-10 Alert

Question: Our patient has returned home after a coronary artery bypass graft (CABG) for coronary atherosclerosis (CAD) of his native artery. We will be providing observation and assessment of the surgical incision on his leg. The wound has three areas of incisional separation but no signs or symptoms of infection. He is a little weak but no longer has chest pain. He also has diabetic peripheral angiopathy. And he has benign prostatic hyperplasia with urinary retention and frequent urinary tract infections. He will soon be scheduled for a transurethral resection of the prostate. We will be providing skilled nursing and physical therapy. How should we code for him?

Iowa Subscriber

Answer: List the following codes for this patient:

• M1020a: 998.32 (Disruption of external operation [surgical] wound);
• M1022b: 414.00 (Coronary artherosclerosis of unspecified type of vessel, native or graft);
• M1022c: 250.70 (Diabetes with peripheral circulatory disorders; type II or unspecified type, not stated as uncontrolled);
• M1022d: 443.81(Peripheral angiopathy in diseases classified elsewhere);
• M1022e: 600.01(Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms [LUTS]); and
• M1022f: 788.20 (Retention of urine, unspecified).

Your patient’s wound is complicated by incisional separation, so you’ll code for it as external disruption with 998.32.

Follow the complicated wound code with the CAD diagnosis because in this case the CABG treated this disease but didn’t cure it.

Next, list 250.70 for diabetes with a circulatory condition, and pair this with 443.81 to indicate the diabetic manifestation — diabetic peripheral angiopathy.

List 600.01 to report your patient has benign prostatic hyperplasia with urinary retention. You’ll notice that the notes under 600.01 ask you list an additional code to identify the particular LUTS, in this case retention of urine (788.20).