Home Health ICD-9/ICD-10 Alert

Question: Our elderly patient has type II diabetic polyneuropathy and a stage II decubitus ulcer on the sacrum. We are seeing him for wound care and dressing changes. How should we code for him?

-- Ohio Subscriber

Answer: List the following codes for this patient, suggests Trish Twombly, RN, BSN, HCS-D, director of coding with Foundation Management Services in Denton, TX.

• M0230a: 707.03 (Pressure ulcer; sacrum);

• M0240b: 250.60 (Diabetes with neurological manifestations; type II or unspecified type, not stated as uncontrolled);

• M0240c: 357.2 (Polyneuropathy in diabetes);

• M0240d: V58.30 (Encounter for change or removal of nonsurgical wound dressing).

Because the focus of care for this patient is his decubitus ulcer, code it in M0230 to indicate that it drives the care for the current certification period, Twombly says.

List the diabetes code (250.60) in M0240 and follow it with the polyneuropathy manifestation code to indicate the diabetes is a comorbidity, not the focus of care, Twombly suggests. Indicate that your patient has type II diabetes not stated as uncontrolled by reporting a "0" in the fifth digit.

Your scenario doesn't indicate that the patient was taking insulin, so don't list V58.67 (Long-term [current] use of insulin).

If the assessing clinician determines that the ulcer and subsequent wound care is routine, then you can list the V code for non-surgical dressing changes (V58.30) at the bottom of the M0240 list. But if the assessing clinician determined that the wound care was complicated, you would leave the dressing changes V code off your list because V codes are used only for routine aftercare, Twombly says.

Leave M0245 blank for this patient because you have a numerical code in M0230, she adds.