Home Health ICD-9/ICD-10 Alert

Unless otherwise indicated, reader questions were answered by Lisa Selman-Holman, JD, BSN, RN, CHCE, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX.

Question: We have a patient who had a total knee replacement two months ago. While being seen by our agency for skilled nursing and physical therapy, she was sent back to the hospital for a coronary artery bypass graft (CABG). She has returned home and we've resumed providing care. She is seeing physical therapy for gait training due to deconditioning, secondary to CABG. Skilled nursing is providing cardiovascular assessment and attention to the incision. How should we code for her?

-- Ohio  Subscriber

Answer: You should determine which of this patient's conditions is the most unstable, most acute or of greatest importance. Is it the deconditioning or the aftercare provided for the cardiac surgery?
If aftercare is your focus, code for this patient as follows:

• M0230a: V58.73 (Aftercare following surgery of the circulatory system, NEC);
• M0240b: V45.81 (Aortocoronary bypass status);
• M0240c: 414.00 (Coronary atherosclerosis; of unspecified type of vessel, native or graft);
• M0240d: 728.87 (Muscle weakness [generalized]); and
• M0240e: V43.65 (Organ or tissue replaced by other means; joint; knee).

Report aftercare first because it is your focus of care. Select V58.73 because your patient's surgery was due to CAD, which falls in the range of conditions classifiable to this aftercare code. The patient has post surgical bypass status, so list V45.81 next.

CAD was the reason for the surgery and still exists, so you should also report 414.00. The lack of activity before and after the CABG resulted in muscle weakness, so you should report 728.87. Add V43.65 to indicate post-surgical status for the joint replacement and to explain further the reason for therapy.

If the weakness is truly the worst condition the patient has, then you could sequence the codes in this order: 728.87, 414.00, V58.73, V45.81, and V43.65.

Warning: If you report muscle weakness as primary for this type of patient, be certain you have thorough documentation as to why you listed this case mix diagnosis (worth 11 points) first.

Don't include a code in M0245 for either situation. In the first scenario, the diagnosis you would have used prior to V codes is CAD, and CAD is not a case mix diagnosis. In the second scenario, the case mix code was already listed as the primary diagnosis.

Question: We are seeing a patient who is recovering from a fractured ankle with an exacerbation of congestive heart failure (CHF). Physical therapy is seeing him three times a week for gait and ambulation issues and nursing is visiting twice a week for CHF issues. The CHF has a higher severity rating, but therapy is providing more visits. How should we code for this patient?

-- Mississippi Subscriber

Answer: Code as primary the condition that is the most acute and most related to the plan of care. Don't automatically conclude that the discipline with the most visits gets its diagnosis listed first. You have indicated the CHF has the highest severity, so code for it first:

• M0230a: 428.0 (Congestive heart failure, unspecified); and
• M0240b: V54.16 (Aftercare for healing traumatic fracture of lower leg).

Question: If a patient is getting both skilled nursing (once a week) and physical therapy (two times a week) for a stent placement surgery after a myocardial infarction two weeks ago, which code would be primary? The patient also has diagnoses of CHF, diabetes and chronic kidney disease. How should I code for this patient?

-- New Hampshire Subscriber

Answer: You have indicated the patient is receiving therapy and nursing for aftercare after the stent. For this patient, list:

• M0230a: V58.73 (Aftercare following surgery of the circulatory system, NEC);
• M0240b: V45.82 (Percutaneous transluminal coronary angioplasty status);
• M0240c: 414.00 (Coronary atherosclerosis; of unspecified type of vessel, native or graft);
• M0240d: 728.87 (Muscle weakness [generalized]);
• M0240e: 410.92 (Acute myocardial infarction; unspecified site; subsequent episode of care);
• M0240f: 428.0 (Congestive heart failure, unspecified); and
• Other pertinent diagnoses: 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled) and 585.9 (Chronic kidney disease, unspecified).

What is the patient's most acute condition requiring the most intensive services? The cardiac aftercare sounds like it will take the most effort because both the nurse and the therapist are providing  aftercare, so this is your primary diagnosis (V58.73).

The reason the patient had the surgery was coronary atherosclerosis. The V code (V58.73) re-placed the CAD diagnosis, so there is no diagnosis listed in M0245.

Question: One of our patients fell from a ladder and sustained a right tibia fracture and left distal radius fracture. Both fractures were repaired. He then developed compartment syndrome in the tibia fracture, requiring a fasciotomy. He had several debridements over the area and then got a muscle graft. He is being sent home with skilled nursing and physical therapy. Skilled nursing will change the dressing to the graft site xeroform and provide dry dressing and scarlet red to the donor site. Physical therapy will provide gait training. How should we code for this patient?

-- Indiana Subscriber

Answer: Code for compartment syndrome as primary with 958.8 (Other early complications of trauma). Aftercare for healing traumatic fracture of the lower leg (V54.16) isn't applicable for this patient because this fracture is complicated.

The patient had surgery to repair the compartment syndrome, so the correct aftercare code for the surgery is V58.43 (Aftercare following surgery for injury and trauma). Choose V58.43 because it covers codes classifiable to 800-900, which includes this patient's traumatic fracture.

You may code V54.12 (Aftercare for healing traumatic fracture of lower arm) for the aftercare you provide to the healing traumatic fracture of the radius, since there is no indication this fracture is complicated.

Don't report a V57.x (Care involving use of rehabilitation procedures) code for this patient because it can only be listed as a primary diagnosis, and therapy isn't the focus of care.

You could also list V58.3 (Attention to surgical dressings and sutures) to indicate the dressing changes.

Leave M0245 blank because there was no V code in M0230.