Home Health ICD-9/ICD-10 Alert

Question: A 73-year-old man with a history of falls fell at home and fractured his left hip. An open reduction internal fixation was performed at the hospital and the patient was discharged home.  The physician orders home health to provide physical therapy for gait training. How would you code this scenario?


California Subscriber


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

 M0230a: V57.1 (Other physical therapy)
 M0240b: 781.2 (Abnormality of gait)
 M0240c: V54.13 (Aftercare for healing traumatic fracture of hip)
 M0240d: V15.88 (History of fall, at risk for falling)
 M0240e: E888.9 (Unspecified fall)
 M0240f: E849.0 (Place of occurrence--home)
 M0245: 781.2 (Abnormality of gait)

Physical therapy is the only service ordered for this patient, so V57.1 is the primary diagnosis. The acute fracture is not used in M0230/M0240 because the condition no longer exists in the home health setting. Because the focus of home care for this patient is gait training, abnormality of gait is the appropriate symptom code.

The patient has a history of falls, so the new V code V15.88 indicates that falls are a problem with this patient.
 
E888.9 shows a fall as the cause of the injury and E849.0 indicates that the fall occurred at home. Although E codes are not required in home health, neither are they prohibited, and using them helps in medical review.