Home Health ICD-9/ICD-10 Alert

Question: Our patient was admitted to home care after a myocardial infarction three weeks ago. She continues to experience symptoms. The medical record indicates that she had 98 percent obstruction in two vessels. She underwent a coronary artery bypass graft (CABG). The wounds are healing well, and we have orders to leave the bypass incision and the leg incision open to air.

She also has hypertension (HTN) that is currently well-controlled and gastroesophageal reflux disease (GERD). She had a below-knee amputation (BKA) two years ago due to diabetic peripheral angiopathy. Her diabetes is currently controlled with diet. We are providing nursing, physical therapy (PT) for strengthening and gait training, and occupational therapy (OT) for energy conservation techniques and activities of daily living (ADLs). Our focus of care is the myocardial infarction, along with aftercare for the CABG.

How should we code for this patient?

Pennsylvania Subscriber

Answer: List the following codes for your patient:

M1020a: 410.92 (Acute myocardial infarction; unspecified site; subsequent episode of care);

M1022b: V58.73 (Aftercare following surgery of the circulatory system, NEC);

M1020c: 414.00 (Coronary atherosclerosis; of unspecified type of vessel, native or graft);

M1022d: 250.70 (Diabetes with peripheral circulatory disorder; type II or unspecified type, not stated as uncontrolled);

M1022e: 443.81 (Peripheral angiopathy in diseases classified elsewhere);

M1022f: 530.81 (Esophageal reflux); and

Other pertinent diagnoses: 401.9 (Essential hypertension; unspecified), V49.75 (Lower limb amputation status; below knee).

Your patient has multiple diagnoses that describe the primary reason for home care. In situations like this, the assessing clinician can choose which diagnosis to list in M1020a. In the suggested code list, the MI is primary, but the clinician could chose to list the aftercare as the primary diagnosis instead. The Face-to-Face documentation from the physician may assist in choosing the primary diagnosis if it is available.

CAD is still present even after a CABG because those vessels containing the plaque are bypassed and not removed. So the CAD is still an existing condition and remains related to the plan of care for this patient.

Your patient’s other co-morbidities should also be reported, provided they accurately reflect the seriousness of the patient’s condition. You can list these co-morbidities in any order. The diabetes along with the peripheral angiopathy will obviously impact the care even though at this time the diabetes is controlled.

GERD has the potential to impact the care for this patient. For example, if the patient is non-compliant with her medications (including pain medications), or her nutrition suffers because of the GERD, or the patient has the potential to confuse the pain of GERD for angina or vice versa, then it will impact the care. That potential should be documented in the record.

Other pertinent diagnoses include her HTN and amputation status.

Whatever your choices are, be sure that your assessment and your plan of care support the diagnoses you list.