Home Health ICD-9/ICD-10 Alert

Question: A diabetic home health patient stepped on a nail that went into her great toe. Two days later, she was admitted to the hospital with an infection of the wound. An incision and drainage is done. The patient develops cellulitis and is transferred to a different hospital, where the toe is amputated. The patient is then discharged to home health on oral antibiotics, dressing changes and weekly venipunctures.

Do we code primary V58.43 (Aftercare following surgery for injury and trauma) or V58.78 (Aftercare following surgery of the musculoskeletal system, NEC), followed by V58.3 (Attention to surgical dressings and sutures)? The diabetes is fairly well controlled. Would we use an E code to identify the initial injury?

Answer: This question illustrates why it is important to have the medical record to refer to when choosing codes. You need to know whether there was still a complicated open wound prior to the amputation or whether the amputation was to prevent the spread of the cellulitis (and perhaps prevent further tissue damage from circulatory disfunction and delayed healing resulting from the diabetes), Dilts-Benson explains.

You need to know more about the diabetes, because it could have impacted the original injury and will definitely impact your care and outcomes, she says. You also need to know the reason for the weekly venipunctures before coding the episode.

One possibility: If the amputation was to stop the spread of infection, use code V58.3 (Attention to surgical dressings and sutures), because the amputation was a surgical procedure, and then V49.71 (Lower limb amputation status; great toe) to give more specific information about why there are dressings to care for, Dilts-Benson suggests.

In addition, use code 681.10 (Cellulitis and abscess of toe, unspecified) because the patient is still on antibiotics to treat the cellulitis and V58.62 (Long-term [current] use of antibiotics) because this is a new medication for the patient and the clinician will need to monitor for side effects and effectiveness, she adds.

Once you know more about the diabetes, chose the appropriate code in the 250.xx series (Diabetes mellitus with codes for the type and manifestations). While not required, an E code to describe the original injury would be informative - E920.8 (Accidents caused by other specified cutting and piercing instruments or objects).

If you're providing the venipuncture to monitor drug levels, use V58.83 (Encounter for therapeutic drug monitoring) to explain that service, Selman-Holman explains.

Another option: If you decide the amputation resulted from the trauma, you would start with V58.43 (Aftercare following surgery for injury and trauma), suggests Selman-Holman, and you would put the trauma code, 893.1 (Open wound of toe[s], complicated), in M0245.