Home Health ICD-9/ICD-10 Alert

Question: Our patient had a fractured tibiafibula fracture six months ago. He had an open reduction with internal fixation and went to the nursing home for nursing care and therapy. Now he is returning home and we will provide physical therapy and occupational therapy for gait training and activities of daily living due to his functional decline. The fracture is healed, so would I code for the patient's diagnoses with a late effect code?

Answer: Yes, a late effects code is appropriate when the patient's initial injury is healed and you are caring for a residual effect. If your patient's original fracture is healed, then you should code for the patient as follows:

• M0230a/M1020a: V57.89 -- Multiple training or therapy

• M0240b/M1022b: 781.2 -- Abnormality of gait

• M0240c/M1022c: 905.4 -- Late effect of fracture of lower extremities

• M0240d/M1022d: 799.3 -- Debility, unspecified

This is a therapy-only case, so it's appropriate to list a V57.x code as your principal diagnosis. Both physical therapy and occupational therapy will be providing services, so your code is V57.89.

When coding for a late effect, list the residual first, followed by the underlying condition that produced the late effect. In your patient's case, this means you'll sequence the abnormality of gait before the fracture.

List these codes in M0240, along with 799.3 to indicate your patient's functional decline.