Home Health ICD-9/ICD-10 Alert

Question: We are providing skilled nursing for observation and assessment of a 75-year-old gentleman recently discharged from the hospital with an acute exacerbation of his chronic systolic and diastolic heart failure. He has significant edema to his lower extremity (LLE) and requires close monitoring of his symptoms and frequent adjustments to his diuretic dosing. He has a complicated medical history including a right below-knee amputation (BKA) related to peripheral vascular disease (PVD) caused by his type 2 diabetes, hypertension (HTN), and Stage IV renal disease. He has chosen not to be on dialysis. How should we code for this patient?

Answer: Code for this patient as follows, says Andrea Manning, BS, RN, HCS-D, COS-C, of Manning Healthcare Group in Talkeetna, AK.:

M1020a: 428.43 (Combined systolic and diastolic heart failure; acute on chronic);

M1022b: 403.90 (Hypertensive chronic kidney disease; unspecified; with chronic kidney disease stage I through stage IV, or unspecified);

M1022c: 585.4 (Chronic kidney disease, Stage IV [severe]);

M1022d: 250.70 (Diabetes with peripheral circulatory disorders; type II or unspecified type, not stated as uncontrolled);

M1022e: 443.81 (Peripheral angiopathy in diseases classified elsewhere); and

M1022f: V49.75 (Below knee amputation status).

Your patient’s heart failure is specified as both systolic and diastolic (combined) and as acute on chronic, Manning points out. Don’t be tempted to choose 428.0 (Congestive heart failure, unspecified) or 428.40 (Combined systolic and diastolic heart failure; unspecified) for this patient. Instead, because the heart failure is specified as acute on chronic, the correct fifth digit for 428.4x is "3," she says.

This patient has documented diagnoses of both hypertension and CKD, so you can assume a relationship between the two and code for them as hypertensive chronic kidney disease with 403.90, Manning says. Remember to choose the fifth digit based on the stage of the CKD. In this case, your patient’s CKD is Stage IV, so the fifth digit is "0". There is no documentation that the CKD is related to the patient’s diabetes, so there is no need to link the diabetes diagnosis to this condition.

Code for your patient’s CKD immediately following the hypertension diagnosis, Manning says. Choose the fourth digit for CKD code 585.x based on the stage of the CKD. In this case, code for Stage IV with the fourth digit "4."

Next, report your patient’s diabetes with 250.70. Select the fourth digit "7" to indicate that your patient has the complication of PVD, Manning says. Your patient’s diabetes is type 2 and not stated as uncontrolled, so the fifth digit is "0."

Following the diabetes code, you’ll need to list 443.81 to indicate that your patient has diabetic PVD, Manning says. Do not code 443.9 (Peripheral vascular disease, unspecified) as a manifestation of diabetes, she says.

Finally, list V49.75 to indicate your patient’s below knee amputation status.

Note: There is no need to include a code for your patient’s LLE edema, Manning says. Edema is an inherent symptom of the combined heart failure. Also, don’t be tempted to move the diabetes to M1020 for case mix points. The focus of the care in this scenario is your patient’s heart failure and this condition should be listed as primary.

And remember that heart failure cannot be automatically related to the hypertension, so the hypertension code is not 404.x in this scenario. To be related to hypertension, the combined heart failure must be stated as in "due to hypertension" or implied as in "hypertensive heart failure" by the physician.