Home Health ICD-9/ICD-10 Alert

Question: Our patient has type 2 diabetes, and we are caring for her diabetic foot ulcer as well as a urinary tract infection with MRSA (methicillin-resistant staphylococcus aureus). The diabetic foot ulcer requires dressing changes every other day, and we plan to teach the family how to administer the IV vancomycin for the MRSA, but nursing will be administering the IV medication until that is possible. Her urinary catheter is to be changed every two weeks. How should we code for this patient?

Vermont Subscriber


Answer: If you will provide the IV administration plus therapeutic drug monitoring for the IV vancomycin, code for this patient as follows, suggests Jun Mapili, PT, MAEd, coding supervisor and director of rehabilitation with Global Home Care in Troy, MI:

• M0230a: 996.64 (Infection and inflammatory reaction due to internal prosthetic device, implant, and graft; due to indwelling urinary catheter);
• M0240b: 599.0 (Urinary tract infection, site not specified);
• M0240c:041.11 (Bacterial infection in conditions classified elsewhere and of unspecified site; staphylococcus aureus);
• M0240d: 250.80 (Diabetes with other specified manifestations; type II or unspecified type, not stated as uncontrolled);
• M0240e: 707.15 (Ulcer of other part of foot);
• M0240f: V09.0 (Infection with microorganisms resistant to penicillins); and

Locator 21 of the Plan of Care 485:

• V58.83 (Encounter for therapeutic drug monitoring).
• V58.62 (Long-term [current] use of antibiotics);
• V58.81 (Fitting and adjustment of vascular catheter); and
• V58.30 (Encounter for change or removal of nonsurgical wound dressing).

While your scenario involves only two major issues, you'll need as many as ten diagnosis codes to describe the care your agency will provide, Mapili says.

Before you can select your first code, you must determine the chief reason for your patient's admission. Is it her diabetic foot ulcer or the urinary tract infection (UTI)? While the patient will be seen every other day for the diabetic foot ulcer, it is the infection (UTI) that would require the most intensive care due to its acuity, Mapili says.

Take care: While diabetes is a case mix diagnosis and would earn 17 points in the current home health PPS, don't let extra points sway your code choice, Mapili warns. Instead, consider the intensity of the services as you select your primary diagnosis. Listing diabetes as the primary diagnosis followed by the diabetic foot ulcer is upcoding in this case, he believes.

Complications such as infections trump V codes, so V53.6 (Fitting and adjustment of other device; urinary catheter) would not be appropriate for this patient. This leaves 996.64 (Infection and inflammatory reaction due to internal prosthetic device, implant, and graft; due to indwelling urinary catheter) as the best choice for primary diagnosis, Mapili says.

Follow this with the code for the infection (599.0) and the organism causing the infection (Staphylococcus aureus, 041.11), and add the code V09.0 for MRSA to denote that the organism is drug-resistant.

In this situation, the foot ulcer is a manifestation of diabetes, so list it after the diabetes.

More often than not, treatment of an MRSA infection requires an encounter of therapeutic drug monitoring (V58.83), such as peak and troughs, Mapili says. Because the patient will be taking antibiotics to treat the infection, it's appropriate to also list V58.62. Report V58.81 to indicate the intravenous administration of vancomycin through a vascular catheter, he says.

Given that the diabetic foot ulcer is not infected and is unrelated to the UTI, V58.30 may apply, because the clinician or nurse will be providing this service to the patient, Mapili says. 

Because the OASIS has room for only six diagnosis codes, you can list the remaining diagnoses in the Plan of Care or form 485/487 in field locator 21, Mapili says.