Home Health ICD-9/ICD-10 Alert

Question: We are providing nursing and physical therapy for an elderly patient with a rotator cuff repair. We don't know whether the rotator cuff tear was traumatic; the patient thinks it was just wear and tear from many years. The nurse will take care of the incision site.

I can't find an orthopedic aftercare code that would apply to this situation. V58.43 (Aftercare following surgery for injury and trauma) is appropriate for conditions classifiable to 800-999, but I don't feel comfortable listing this since we don't know if the injury was due to a trauma. What are the right codes to report?

Answer: Reference "Tear, torn," subterm "rotator cuff" in the alphabetic index of your ICD-9 manual. Under that term you will find degenerative (726.10) and nontraumatic (727.61).

The code 726.10 (Disorders or bursae and tendons in shoulder region, unspecified) is for rheumatism and rotator cuff syndrome of the shoulder and includes rotator cuff syndrome not otherwise specified. The code 727.61 (Complete rupture of rotator cuff) is for nontraumatic complete rupture of the rotator cuff.

Ask the physician for additional information, but if information is not available, choose 726.10, because of the NOS convention. The correct aftercare code is V58.78 (Aftercare following surgery of the musculoskeletal system, NEC).

The codes for rotator cuff syndrome are Ortho 2 case mix diagnoses so remember to list them in M0246. Points are available only if the patient has infusion or parenteral therapy.