Home Health ICD-9/ICD-10 Alert

Reader questions were reviewed by Lynda Dilts-Benson, RN, CCM, CRRN, CRNAC, LHRM, HCS-D, a consultant with Reingruber & Co. in St. Petersburg, FL.

Q: A patient fell in November and injured his elbow. He had an x-ray at the ER where doctors found bleeding into the bursa, but did not suggest any other treatment. In December the patient went to the doctor because of pain, swelling and inflammation in his arm at the injury site. The doctor sent him to a wound clinic where they probed the area, removed pus and cleaned it. Now he is admitted to home health for wound care, including packing the wound. Is this coded as an 800 code for complicated open wound to upper limb or as a surgical wound because of the incision and drainage? 

A: This appears to be a late effect from a trauma, which required an incision and drainage. The wound is now a surgical wound. It can't be coded as a complicated or infected open wound unless the physician documented it that way, Dilts-Benson explains.

For example, the physician could have called it an infected hematoma secondary to the initial trauma. If the record is not clear, the agency should call the physician's office for clarification. The physician would not be likely to call the wound a complicated or infected surgical wound, because that would mean it got infected or complicated after the surgery, she adds.

Q: The patient had surgery to remove a skin lesion. How do we code this when the surgical wound (not infected) is left open to heal by secondary intention?

A: You need more information about the skin lesion to code this correctly, Dilts-Benson says. In this type of healing, a full-thickness wound is allowed to close and heal. Secondary healing results in an inflammatory response that is more intense than with primary wound healing. But that doesn't change the choice of codes.
 
Your primary code will be a V code for aftercare following surgery. If you know the skin lesion was a neoplasm, then the code would be V58.42 (Aftercare following surgery for neoplasm) - which is used for conditions classifiable to codes 140-239.
 
When you look in the record - or check with the physician - to determine the kind of lesion, you can also determine if it was malignant or benign. And from the assessment, you will know the location of the lesion, so you can code the correct description of the lesion.
 
Tip: Because you have an uncomplicated surgical wound,  do not use any of the injury codes from chapter 17.

Q: Is 788.3 the right ICD-9 code to report for urinary incontinence, as of Oct. 1, 2004?

A: Start with the 788.3 series, but for urinary incontinence the ICD-9 manual requires you to code to the 5th digit. On Oct. 1, 2004, ICD-9 added 788.38 (Overflow incontinence) to the series. None of the other code descriptors for 788.30-788.37 and 788.39 have changed.

Q: In coding decubitus ulcers, when would I use 707.00 (Decubitus ulcer, unspecified site) rather than 707.09 (Decubitus ulcer, other site)?

A: Think of 707.00 as lack of information and 707.09 as lack of a specific code. While 707.00 will be used in other settings, you are unlikely to use this code very often in home care. Assigning diagnosis codes in home care follows the clinician's admission assessment. The clinician will know exactly where the decubitus ulcer is. If the location is not in the documentation, you need to contact the clinician to find out.
 
On the other hand, use 707.09 when the ICD-9 codes do not contain a code for the site specified. For example, there is not a specific code for a decubitus ulcer on the calf, so if that is the location, you would code 707.09.

Q: We have an Alzheimer's patient with frequent sleep disturbances. Do we report a diagnosis code for sleep disturbance in addition to the Alzheimer's diagnosis code even though sleep disturbance results from Alzheimer's?

A: Sleep disturbance is a common side effect of Alzheimer's disease, and as such, it is considered relevant to the patient's care. You should report 780.59 (Sleep disturbance, other) as a secondary diagnosis code in M0240. If the primary reason for home care is the Alzheimer's, that should go in M0230. Many Alzheimer's patients also have hallucinations and other similar symptoms. If that is true for this patient, you can assign diagnosis code 780.1 for these symptoms.

Q: We have a patient admitted for home care after having a portion of his bowel removed along with a malignant tumor in his colon. He is undergoing chemotherapy for that cancer now. Should we still code the colon cancer?

A: Yes, code the colon cancer as if it is a current condition. Even though the tumor was removed, you need to code for it as though it still exists because the cancer is still being treated. You'll be choosing a 153.x code (Malignant neoplasm of colon). You need a 4th digit for the specific location in the colon. Be sure to ask the physician for more information if the exact code isn't clear from the record.