Home Health ICD-9/ICD-10 Alert

Question: Our patient has esophageal cancer. He had a g-tube placed in preparation for radiation to the esophagus. Three days after the tube was placed he was admitted to the hospital with a gastric perforation, abdominal wall abscess. They performed an evacuation of abscess, repaired the perforation, removal of gtube, and insertion of a new g-tube. We will be doing daily wound care to the surgical site, packing the lower portion of the incision site, and daily g-tube flushes. He will be on oral antibiotics. How should we code for him?

Answer: Code for this patient as follows:

• M1020: 536.41 (Infection of gastrostomy)

• M1022: 682.2 (Other cellulitis and abscess; trunk)

Because you are providing care for an infected gastrostomy site, 536.41 is your principal diagnosis. The perforation was repaired at the hospital, so it's not appropriate to list 536.42 (Mechanical complication of gastrostomy).

The notes next to 536.41 instruct you to use an additional code to identify the type of infection. In your patient's case, that's 682.2 for the abscess. You should also list a code for his esophageal cancer, according to the exact location and whether the cancer is primary or secondary.