Home Health ICD-9/ICD-10 Alert

Question: Our patient was referred to home care following a cholecystectomy due to acute cholecystitis. She also has a history of breast cancer and is taking Tamoxifen prophylactically. She’s had some problems with urinary retention after surgery and one of her surgical wounds is dehisced. We will be discontinuing the indwelling catheter and instructing her on how to use an intermittent catheter. How should we code for this patient in ICD-9 and how will our coding change for ICD-10?

Florida Subscriber

Answer: Code for this patient as follows, says Lisa Selman-Holman, JD, BSN, RN, COS-C, HCS-D, HCS-O, AHIMA Approved ICD-10-CM Trainer/Ambassador of Selman-Holman & Associates,  CoDR—Coding Done Right and Code Pro University in Denton, Texas:

• M1020a: 998.32 (Disruption of external [surgical] operation wound);
• M1022b: 788.20 (Retention of urine, unspecified);
• M1022c: V53.6 (Fitting and adjustment of urinary device);
• M1022d: V07.51 (Use of selective estrogen receptor modulators [SERMs]); and
• M1022e: V10.3 (Personal history of malignant neoplasm of breast).

Your patient is experiencing a complication of her surgery, so your principal diagnosis can’t be aftercare code V58.75 (Aftercare following surgery of the teeth, oral cavity and digestive system, NEC). Instead, 998.32 to indicate her dehisced surgical wound is your first-listed code.

Next, list 788.20 to report her urinary retention and V53.6 to indicate the catheter care you will be providing.

Finally, V codes V07.51 and V10.3 show your patient’s history of cancer and prophylactic use of Tamoxifen.

In ICD-10, you’ll list the following codes for this patient:

• M1021a: T81.31xD (Disruption of external operation [surgical] wound, not elsewhere classified);
• M1023b: R33.9 (Retention of urine, unspecified);
• M1023c: Z46.6 (Encounter for fitting and adjustment of urinary device);
• M1023d: Z79.810 (Long term [current] use of selective estrogen receptor modulators [SERMs]); and 
• M1023e: Z85.3 (Personal history of malignant neoplasm of breast).

Although the codes look different in ICD-10, the logic you’ll follow to find them won’t change.