Home Health ICD-9/ICD-10 Alert

Question: Our new patient was admitted to home care after being discharged from the hospital following craniotomy and evacuation of an intracerebral hemorrhage. The injury resulted from a fall from a ladder at home. He was diagnosed with a traumatic intracerebral hemorrhage with brief loss of consciousness and open wound to the forehead. An X-ray showed no fracture.

The patient is experiencing cognitive deficits and requires a skilled nurse to assess and monitor his condition and to provide wound care to the surgical wound and the trauma wound to the forehead. A physical therapist will work with him to regain his mobility, and provide gait training and safety measures. The physician describes these deficits after the head injury as post traumatic brain syndrome.

Pennsylvania Subscriber

Answer: Code for this patient as follows:

• M1020a: V58.43 (Aftercare following surgery for injury and trauma);
• M1022b: 873.42 (Other open wound of head, face, without mention of complication, forehead);
• M1022c: 310.2 (Posttraumatic brain syndrome, nonpsychotic);
• M1022d: 907.0 (Late effect of intracranial injury without mention of skull fracture); and
• M1022e: V58.31 (Encounter for change or removal of surgical wound dressing).

Aftercare code V58.43 is your go-to when the patient has had surgery to repair an injury but requires continued care during the recovery phase.

Code for your patient’s wound with 873.42 and list 310.2 for his cognitive deficits and mobility problems related to the traumatic brain injury.

Because the post traumatic brain syndrome is the late effect of a traumatic injury, list a code from the 905-909 (Late effects of injuries, poisonings, toxic effects, and other external causes) series next. If the physician had not documented post traumatic brain syndrome, the memory loss would be documented as 310.89 (Other specified nonpsychotic mental disorders following organic brain damage) and you would code for the abnormality of gait with 781.2.

Finally, include V58.31 and V58.30 to indicate the dressing changes.

Be careful: Don’t use code 438.0 (Late effects of cerebrovascular disease, cognitive deficits) for this patient. His late effects are due to a traumatic injury, not a CVA. You could also include the optional E code E881.0 (Accidental fall from ladder).

Note: If you were coding this aftercare scenario in 2012 and the head injury was still acute, you would have reported 853.02 (Traumatic cerebral hemorrhage with brief loss of consciousness) in M1024 across from aftercare V code V58.43. But as of Jan. 1, 2013, changes to the Home Health Prospective Payment System grouper limit M1024 to fracture codes only. So if the head injury was still acute you would now report 853.02 immediately following V58.43 and still earn the primary Neuro 1 points.

However, you cannot code the acute head injury and the late effects of the same injury at the same time. The care in the scenario as it stands is directed to the deficits of the head injury and not to the head injury itself -- that gives you the clue that this is a late effect situation.