Home Health ICD-9/ICD-10 Alert

Question: Your newest patient is a 79-year-old man who fell when he was getting out of his car on a slight incline, and the car rolled because it wasn't parked correctly. He hit his head and had a subdural hematoma that was surgically drained during his hospitalization. He is admitted for rehabilitation, with physical, occupational and speech therapy, with ST expected to be in most often at first. Nursing will be doing some assessment and teaching. He has aphasia, blurred vision, left-side weakness (he is right handed) and tremor and slurred speech. How would you code this patient?

Answer: Code this scenario as follows, suggests Laresa Boyle, director of coding services at Longview, TX-based Healthcarefirst :

M0230  V58.42  (Aftercare following surgery for injury and trauma)

M0240  784.3    (Aphasia) 

            342.92  (Hemiplegia unspecified, affecting non-dominant side) [OR if you can confirm the tremors are really spasms associated with the hemiplegia, code 342.12  (Hemiplegia, spastic affecting non-dominant side)]. 
       
           368.8    (Blurred vision)

          V57.89 (Multiple or other therapies)

M0245  852.20  (Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness)

Because the hematoma was drained during surgery, he no longer has a hematoma, so use the aftercare code as primary. The code in M0245 adds 20 points to the clinical domain. The tremors may indicate spastic paralysis, so query the clinician about this possibility before choosing the code, adds coding consultant Lisa Selman-Holman. There is not a separate code in this answer for slurred speech because that symptom can be considered part of aphasia.

You may be able to find the specific E code for the accident if you can gather a bit more information. You could use E825.0 (Other motor vehicle nontraffic accident of other and unspecified nature, driver of motor vehicle other than motorcycle), if the vehicle was in a parking lot, because this code includes falling from a motor vehicle while in motion, not on a public highway. If the patient fell because the moving car knocked him over after he was outside the vehicle, he could be considered a pedestrian and E822.7 (Other motor vehicle non-traffic accident involving collision with moving object, pedestrian) applies. This code includes a collision not on a public highway between a moving car and a pedestrian.