Home Health ICD-9/ICD-10 Alert

Question: We have a patient who has returned home from the hospital after falling. We are providing physical therapy and occupational therapy. She has a head laceration and a wrist contusion. She has a history of falls, gait abnormality, and generalized weakness. She also has a history of coronary artery disease and hypertension. How should I code for her?

Answer: Because this is a therapy-only case, you may code V57.89 (Multiple therapies) as primary. If you can determine a more definitive diagnosis for the falls, the definitive diagnosis is a better choice than abnormality of gait (781.2).

Code for coronary artery disease with 414.00 (Coronary arthero-sclerosis; of unspecified type of vessel, native or graft) and report the hypertension with 401.9 (Essential hypertension; unspecified).

Also list the head laceration, wrist contusion and personal history of falls (V15.88).

Gait abnormality and generalized weakness are both symptom codes. Use these ICD-9 codes only if a more definitive diagnosis cannot be determined.