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.

Take The Stress Out Of Coding For Fractures

Q: We admitted a patient for physical therapy after an insufficiency fracture of the pelvis. I know we plan to use V57.1 (Other physical therapy) as the primary diagnosis, but where do I find the code for the fracture?

A: An insufficiency fracture is a type of stress fracture, so generally look to 733.95 (Stress fracture of other bone). Insufficiency fractures often occur in patients with osteoporosis (typically a 733.0x [Osteoporosis] code), so you may be able to report this code as well, if documentation supports this code.

You might be tempted to report this as a pathologic fracture (733.1x) because this stress fracture results from normal or physiologic stress on a weakened bone, but technically it is a stress fracture. If you have any doubt, ask the physician for a more specific diagnosis.

When Do You Code The Underlying Alzheimer's?

Q: We have a number of Alzheimer's patients. When is Alzheimer's disease an  appropriate primary diagnosis?

A: To make this determination, you must identify the most intensive services you are providing in the home. If your plan of care focuses on Alzheimer's in general - such as educating the caregiver or family about the stages and progression of the disease process, safety, medication effects or side effects, what to report to the physician, emergency procedures, or ways to promote and maintain function for as long as possible - you are primarily addressing the Alzheimer's. In this case you can use the Alzheimer code as primary.

But if you are primarily treating a decubitus ulcer for a bedridden Alzheimer's patient, or are monitoring the patient's congestive heart failure, the Alzheimer's is not the main reason for home care, so it should not be the primary diagnosis. Instead, here you would code the decubitus or the heart failure.

Q: What code do you use when the primary reason for home care is pain management?

A: If the primary reason for home care is pain management, then you need to code where the pain is and what is causing it. Any underlying conditions should also be included, as well as any surgical aftercare issues, if they exist. If the patient is receiving palliative services, which include pain management as the primary function, then be sure to include V66.7 (Encounter for palliative care), making sure that you code first the underlying disease, as well as where the pain is.

Consider Symptom Codes A Last Resort

Q: Could you give me some examples of when we would use a symptom code in home care?

A: Symptom codes are only used when a physician has not made a definitive diagnosis. For example, if a patient has had an alteration in their mental status, but there is no diagnosis of Alzheimer's disease or any other form of dementia, delirium, etc., then you would code just the altered mental status.

Another example: If you have been given a referral to admit a patient to home health services for back pain, and there is not a definitive diagnosis in the record by the time the OASIS is due, or the physician has not completed the diagnostic procedures to specify the diagnosis behind the pain, then you would code the back pain.

If you have used a symptom code and later receive a documented diagnosis, you can wait until the next scheduled OASIS to change the diagnosis codes.

Q: We are seeing a patient at home for daily subcutaneous infusions of Desferal as a treatment for chronic iron overload. How would I code this?

A: Chronic iron overload is also known as hemochromatosis. Look in your coding manual under iron storage disease or iron metabolism. These terms lead you to  275.0 (Disorders of iron metabolism), which includes hemochromatosis.

Is V58.67 Primary?

Q: If I'm caring for an insulin-dependent diabetic patient whose Type II diabetes is uncontrolled, should I use V58.67 (Long-term [current] use of insulin) as a primary or secondary diagnosis?

A: The fact that the patient is on insulin is not the reason for the health care encounter, says Sue Bowman with the American Health Information Management Association in Chicago, so you would use V58.67 only as a secondary diagnosis. The underlying diabetes would be coded first, she instructs.
 
If the patient has uncontrolled Type II diabetes, the code to use is 250.x2, with the fourth digit specifying whether the diabetes is uncomplicated or has manifestations - for example, 250.02 (Diabetes mellitus, without mention of complication, Type II or unspecified type, uncontrolled) or 250.12 (Diabetes with ketoacidosis, Type II or unspecified type, uncontrolled). Be sure the physician has stated that the diabetes is uncontrolled before you code it that way, experts say.