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Give This Hip replacement Coding Scenario A Try

Published on Wed Mar 14, 2007

Question: Our diabetic patient had hip joint replacement surgery and was discharged to home care. He has an open incision, and nursing will visit to watch for signs of infection and change the dressings. Physical therapy will visit to provide gait training. How should we code for this patient?

Washington Subscriber

Answer: List the following codes for this patient, suggests Rhonda Will, RN, BS, COS-C, HCS-D, senior clinical consultant with Northamp-ton, MA-based Fazzi Associates:

  • M0230a: V54.81 (Aftercare following joint replacement);
  • M0240b: 781.2 (Abnormality of gait);
  • M0240c: 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled);
  • M0240d: V43.64 (Organ or tissue replaced by other means; joint; hip);
  • M0240e: V58.31 (Encounter for change or removal of surgical wound dressing); and
  • M0245a: 781.2 (Abnormality of gait).

List V54.81 in M0230 because the plan of care (POC) includes proposed interventions by both disciplines and the diagnosis driving the POC is aftercare following a joint replacement, Will says. Aftercare codes describe routine follow-up care in the recovery and rehabilitation phase of a condition. In this scenario, there is no evidence of complications and the services provided are routine follow-up and postsurgical care for a hip replacement.

Buttress Your Selection With These Guidelines

The Medicare Program Integrity Manual directs coders to list secondary diagnoses that best reflect the seriousness of the patient's condition and to justify the disciplines and services provided, Will says. The number and severity of secondary diagnoses affect risk adjustment for the calculation of patient outcomes, she adds.

Add to these coding requirements the ICD-9 Coding Manual, which instructs coders to list additional codes in select instances and dictates the order sequencing of certain codes. Finally, the OASIS Implementation Manual says that when a V code is the primary diagnosis and replaces a case mix code, you may complete M0245 to capture the clinical points for reimbursement.

Smart: Follow Will's rule of thumb: Unless there is a direction from one of the preceding authorities to the contrary, sequence the V codes included in the list of secondary diagnoses at the bottom for the best risk adjustment.

The abnormality-of-gait diagnosis supports the need for therapy services. It's the right code to use when describing the gait impairment that results from an orthopedic surgical procedure, Will says. Although the underlying diagnosis to the V code is most likely degenerative joint disease -- which is not a case mix diagnosis -- ICD-9 coding guidelines allow you to use a symptom code when the definitive diagnosis is no longer appropriate.

Always: List a diabetes code because it is a multi-systemic disease that has the potential to affect the patient's rehabilitation prognosis and responsiveness to treatment, Will says. Coding guidelines require the doctor to determine the type of diabetes and whether the disease is controlled. Lacking that clinical information in this scenario, the default type is type II, and not stated as uncontrolled. Therefore, list 0 for the fourth and fifth digits, she says.

Instructional notes in your ICD-9 manual under V54.81 require you to use an additional code to identify the joint replacement site, so add code V43.64 for replacement of hip joint. And the code for attention to surgical wound dressings describes one of nursing's planned skilled interventions.

Helpful: To complete M0245, determine which condition would drive this plan of care if you weren't allowed to use a V code, Will says. Consider the interventions of each discipline, the reasons for them and typical treatment patterns. Report abnormality of gait in M0245 if the number of therapy visits ordered indicates a greater intensity of therapy services than nursing services. Attachment D to Chapter 8 of the OASIS Implementation Manual provides additional guidance.

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