Home Health ICD-9/ICD-10 Alert

Question: Our patient has had his right leg amputated below the knee due to peripheral vascular disease secondary to uncontrolled type 2 diabetes. We have been asked to provide physical therapy and occupational therapy. How should we code for this patient?



Virginia Subscriber



Answer: If therapies are the only services, the correct sequence is:

V57.89 (Other specified rehabilitation procedure, multiple training or therapy); 781.2 (Abnormality of gait); 
250.72 (Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled); 
443.81 (Peripheral angiopathy in diseases classified elsewhere); and
V49.75 (Lower limb amputation status, below knee). 
V58.73 (Aftercare following surgery of the circulatory system, NEC) could also be added.

Therapy will be coded first. The therapies are the primary services being provided and they are treating the abnormality of gait so it is coded before the diabetes. As of Dec. 1, the codes in the V57 category can only be reported for primary diagnoses. So, V57.89 for multiple therapies indicates that the primary reason for homecare is rehabilitation.