Home Health ICD-9/ICD-10 Alert

Reader questions were answered by Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas.

Question: We have a controlled, type II diabetic patient without mention of complication. She underwent a total knee replacement due to localized degenerative joint disease (DJD) and is recovering from the surgery. The incision requires dressing changes due to the drainage of bloody fluid. There is no sign of infection. We are also providing physical therapy for her. How should we code for this patient?

-- Oklahoma Subscriber

Answer: List the following codes for your patient:

• M0230a: V54.81 (Aftercare following joint replacement) M0246: 715.36 (Osteoarthrosis, localized, not specified whether primary or secondary; lower leg);

• M0240b: 781.2 (Abnormality of gait);

• M0240c: 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled); and

• M0240d: V58.31 (Encounter for change or removal of surgical wound dressing).

Because both nursing and therapy are involved, it's not appropriate to list V57.1 (Other physical therapy).

Both therapy and nursing are seeing the patient for aftercare of the joint replacement. The underlying condition to the V code is the localized DJD, so you should place 715.36 in M0246.

Abnormality of gait is the symptom resulting from the surgery and is being treated by therapy, so list 781.2 next.

Diabetes is a co-morbidity that may impact the care so you should code for it even if it is controlled. In this case, list 250.00.

Lastly, add the V code for dressing changes to better specify the aftercare you are providing.