Home Health ICD-9/ICD-10 Alert

Question: Our patient sustained a left distal femur fracture due to a fall. The fracture was not surgically repaired, but she is using ace support. She has a foley catheter for incontinence. She also has a history of left-sided weakness, (right sided dominant) documented "cerebral infarct" or "mini-strokes." She also has a history of constipation, dementia related to infarcts and malnutrition. 

I know we don't mention the fracture as a primary or secondary diagnosis if it has been repaired, but what do we do if it hasn't? How should I code for this patient?


Texas Subscriber

Answer: If the aftercare for the fracture is your primary reason for care, then V54.15 (Aftercare for healing traumatic fracture of upper leg) is your primary code. Use the V54.1x codes to indicate aftercare for a healing fracture. The patient doesn't need to have had surgery for you to report these codes. Also include 438.22 (Late effects CVA with hemiplegia affecting non-dominant side), 438.89 (Late effects CVA), 290.4x (Vascular dementia), V53.6 (Fitting and adjustment of a urinary device), and a code to describe the type of incontinence your patient has, such as 788.31 (Urge incontinence). Sequence the codes according to your Plan Of Care.

Unless otherwise indicated, reader questions were answered by Lisa Selman-Holman, JD, BSN, RN, CHCE, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX.