Home Health ICD-9/ICD-10 Alert

Question: Our patient had an acute myocardial infarction (MI) five weeks ago. She had ventricular fibrillation and has an implanted defibrillator. She had a stent placed at the hospital and returned home. The physician documentation states that she has muscle weakness. We are providing physical therapy only. How should we code for her?

Answer: List the following codes for your patient:

• M1020a: V57.1 (Other physical therapy);
• M1022b: 410.92 (Myocardial infarction unspecified; subsequent episode of care);
• M1022c: 728.87 (Muscle weakness [generalized]); 
• M1022d: V45.02 (Automatic implantable cardiac defibrillator in situ); and
• M1022e: V45.81 (Aortocoronary bypass status).

Your agency is providing physical therapy only for this patient, so your first-listed code is V57.1. 

Next, list 410.92 to indicate that your patient had an MI. This code is only appropriate to list when your care occurs within eight weeks of the MI. After that time, you would look to 412 (Old myocardial infarction) or 414.8 (Other specified forms of chronic ischemic heart disease) if your patient is experiencing MI symptoms.

Follow this with 728.87 for her muscle weakness.

Finally, report V45.02 to indicate that your patient had a defibrillator placed and V45.81 to indicate the angioplasty (stent placed).

In ICD-10 for this patient, you would list:

• M1021a: Z48.812 (Encounter for surgical aftercare following surgery on the circulatory system); 
• M1023b: M62.81 (Muscle weakness [generalized]);
• M1023c: Z95.810 (Presence of automatic [implantable] cardiac defibrillator); and
• M1023d: Z95.5 (Presence of coronary angioplasty implant and graft).

The rules for reporting MIs will change when you transition to the ICD-10 code set. In ICD-10, you’ll report an acute MI code only when the MI is equal to or less than four weeks old. If coding for a current MI, you will look to I21.-- (ST elevation [STEMI] and non-ST elevation [NSTEMI] myocardial infarction) and I22.- (Subsequent ST elevation (STEMI) and non-ST elevation [NSTEMI] myocardial infarction).

For patients who had an MI greater than four weeks ago and are still experiencing symptoms or require care, you’ll look to the aftercare codes. In your patient’s case, Z48.812 indicates that she requires care following the stent placement.

Tip: For patients who experienced an MI in the past, look to I25.2 (Old myocardial infarction).

Follow the aftercare code with M62.81 for her muscle weakness. 

Finally, list Z95.810 to indicate the defibrillator and Z95.5 to indicate that she had a stent placed.