Home Health ICD-9/ICD-10 Alert

Question: How should I code for a patient with the following diagnoses: peripheral vascular disease, gastroesophageal reflux disease and ambulatory dysfunction?

Answer: Before anyone can help you with coding this patient, you must determine the primary reason for home care.

First the basics: The code for peripheral vascular disease without any more specific information provided is 443.9 (Peripheral vascular disease, unspecified). But your assessing clinician should be investigating if this PVD is arterial or venous.

Example: Is the skin taut and shiny or is there edema and a brownish discoloration of the skin, for example? Is there pain? Do rest and/or elevation relieve the pain?

There are different codes for venous insufficiency and arterial insufficiency. By assessing more closely, the clinician can provide information that allows you to be more specific with the codes for this patient.

In addition, the plan of care depends on a complete assessment. For example, it would not be appropriate to instruct a patient with arterial disease to elevate the legs.

Next: For the gastroesophageal reflux disease (GERD) you use diagnosis code 530.81 (Esophageal reflux). As of Jan. 1, this code is a case mix diagnosis.

Finally: Ambulatory dysfunction is a non-specific term, and the most likely diagnosis code is abnormality of gait. However, abnormality of gait is a symptom code and, again, the assessing clinician should investigate further to determine if there is a definitive reason for this "dysfunction."

If the clinician can't determine a definitive reason, she should indicate whether abnormality of gait is the correct code to use.

Example: If the gait issue is because of an old injury to the leg or arthritis, then abnormality of gait would not be the correct code.