Home Health ICD-9/ICD-10 Alert

Question: Our patient was burned extensively two years ago on her chest, arms and head. She underwent surgery recently for bilateral reduction mammoplasty (due to scar tissue), right axillary contracture release, and tissue expander insertion into scalp for treatment of burn alopecia. We are providing wound care to scalp and chest. Should we code aftercare for surgery for injury and trauma, or late effect of burn, or other specified aftercare following surgery? The patient is also on prophylactic antibiotics.


Indiana Subscriber

Answer: Code for this patient as follows, suggests Joella Teague, LVN, HDS-D, coding specialist with Angel Bright Home Health, in Corpus Christi, TX:

• M0230a: V58.77 (Aftercare following surgery of the skin and subcutaneous tissue, NEC);

• M0240b: V58.31 (Encounter for change or removal of surgical wound dressing);

• M0240c: 704.00 (Alopecia, unspecified);

• M0240d: 906.5 (Late effect of burn of eye, face, head, and neck);

• M0240e: V58.62 (Long-term [current] use of antibiotics); and

• M0240f: E929.4 (Late effects of accident caused by fire).

Look to the most recent ICD-9-CM Official Guidelines for Coding and Reporting, effective Nov. 15, for specific guidance on coding burns, Teague says.

The section of the guidelines, "encounter for treatment of late effects of burns" advises: "En-counters for the treatment of the late effects of burns (i.e., scars or joint contractures) should be coded to the residual condition (sequelae) followed by the appropriate late effect code (906.5-906.9). A late effect E code may also be used, if desired." Following this guideline, the surgical interventions in this case were performed for residual conditions classified to 680-709 (Diseases of the skin and subcutaneous tissue), she says.

To find the correct aftercare code for this patient, turn to the alphabetic index of your ICD-9 manual and locate the main term "aftercare," the subterm "following surgery," and the essential modifiers "skin" and "subcutaneous tissue," Teague says. This search will direct you to V58.77.

But before you assign this code, you must first verify it in the tabular list of your ICD-9 manual, Teague says. Here, you'll find a note indicating that code V58.77 (Aftercare following surgery of the skin and subcutaneous tissue, NEC) is appropriate for conditions classifiable to 680-709. 

Next, list V58.31 (Encounter for change or removal of surgical wound dressing), Teague says. This new subclassification code for attention to surgical dressings and sutures became effective Oct. 1.

Follow this with 704.00 (Alopecia, unspecified), the late effect residual condition that was unresolved by the surgical intervention, and then list the late effect code 906.5 (Late effect of burn of eye, face, head, and neck), Teague says. To locate a late effect code, look for the main term "late" in the alphabetic index. Late effect codes for burns have further differentiation depending on the location of the burn.

List V58.62 (Long-term [current] use of antibiotics) to report the prophylactic use of antibiotics, Teague says. The guidelines for V58.6 state that this subcategory indicates a patient's continuous use of a prescribed drug for long-term treatment of a condition or for prophylactic use.

Finally, list E929.4 (Late effects of accident caused by fire). To find this code, look under the term "late" in the index to external causes (also known as the "E code index.") This code is appropriate for use to report late effects of accidents classifiable to E890-E899 (Accidents caused by fire and flames). Coding guidelines for late effect E codes advise you to list a late effect E code with any report of a late effect or sequela resulting from a previous injury.