Home Health ICD-9/ICD-10 Alert

Question: Our new patient was admitted for surgical aftercare of a hip joint replacement due to a fracture. She also has a staph-infected stage 2 pressure ulcer of the heel. While in the hospital, she fell, resulting in a trauma wound to the tendon on her forearm. Nursing and therapy will be providing care for her. How should we code for this patient?

-- Missouri Subscriber

Answer: List the following codes for this patient, says Tricia A. Twombly, BSN, RN, HCS-D, CHCE senior education consultant and director of coding with Foundation Management Services in Denton, Texas:

M1020a: V54.81 (Aftercare following joint replacement)

M1024: 820.8 (Fracture of unspecified part of neck of femur, closed)

M1022b: 707.07 (Pressure ulcer; heel)

M1022c: 707.22 (Pressure ulcer stage II)

M1022d: 041.10 (Staphylococcus, unspecified)

M1022e: 881.20 (Open wound of elbow, forearm and wrist; with tendon involvement; forearm)

M1022f: V43.64 (Organ or tissue replaced by other means; hip)

Because both nursing and therapy will be providing aftercare for this patient, it's not appropriate to list a V57.x (Care involving use of rehabilitation procedures) code, so V54.81 is your principal diagnosis code, Twombly says.

Report 820.8 in M1024 next to V54.81. The hospital provided care for the fracture, but it is also the root of the reason you are caring for the patient, and by placing it in M1024 you may earn case mix points.

To report the patient's staph-infected pressure ulcer, you will need to list three codes. Listing 707.07 indicates the site of your patient's pressure ulcer (heel), 707.22 shows that it's a stage II pressure ulcer, and 041.10 indicates that the pressure ulcer is infected with staph.

If you know whether the staph is Staph aureus or methicillin resistant, you could list one of these more detailed codes to describe the infection: 041.11 (Methicillin susceptible Staphylococcus aureus) or 041.12 (Methicillin resistant Staphylococcus aureus).

Next, list 881.20 to describe your patient's trauma wound. 881.20 is an open wound code that should only be used when the condition rises to the level of a trauma wound. The clinician's documentation should include measurements and pictures of the wound, and describe wound care that requires the skill of clinician. If criteria is not met for a trauma wound, it should be coded as a superficial injury. And finally, V43.64 indicates that it's your patient's hip joint that was replaced.