Home Health ICD-9/ICD-10 Alert

Question: When providing aftercare for a patient who is recovering from hip replacement surgery, do we need to list abnormality of gait and muscle weakness as diagnosis codes, or are these considered symptoms integral to recovering from a hip replacement?

-- Kansas Subscriber

Answer: In this example, it's appropriate to code abnormality of gait. You can code for symptoms, signs, and ill-defined conditions when the definitive diagnosis is unknown or resolved. In the case of a joint replacement, the arthritis in that particular joint is resolved, so what is being treated is the symptom remaining -- abnormality of gait.

But remember, abnormality of gait is not the underlying condition to V54.81. Instead, you must code the reason the patient had the joint replacement. This cause is usually degenerative joint disease -- coded with 715.xx (Osteoarthrosis and allied disorders) --or a fracture.