Home Health ICD-9/ICD-10 Alert

Question: We have a controlled type II diabetic patient without mention of complication. She underwent a total knee replacement and is recovering from the surgery. We are providing aftercare and physical therapy. The incision requires dressing changes due to the drainage of bloody fluid. There is no sign of infection. How should we code for this patient? 


South Carolina Subscriber


Answer: For this patient, list the following codes, says Jun Mapili, PT, MAEd, rehab therapies supervisor with Global Home Care in Troy, MI.

• M0230a: V57.1 (Other physical therapy);
• M0240b: 781.2 (Abnormality of gait);
• M0240c: V54.81 (Aftercare following joint replacement);
• M0240d: V43.65 (Organ or tissue replaced by other means; joint; knee)
• M0240e: V58.31 (Encounter for change or removal of surgical wound dressing);
• M0240f: 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled); and
• M0245a: 781.2 (Abnormality of gait).

Sequencing the six codes that best describe this scenario is the tricky part, Mapili says. Before you can determine the primary diagnosis, you have to determine the chief reason for the admission.

You must also decide whether the case is complicated or not. If there is a complication, such as infection or delayed healing, you should report a complication code rather than a V code.

To code precisely, you should know how many days post-surgery this patient is and have an idea of the amount of bloody discharge, Mapili says. You'll need to investigate further to gather these details.

A minimal amount of bloody fluid could be considered normal right after this surgery, and since there is no infection noted, the V code would be applicable. Given that this is an uncomplicated physical therapy-only case, V57.1 is an appropriate primary diagnosis code.

Your next step is to determine which code was replaced by V57.1 so you can decide whether you should report a case mix code in M0245 for payment. If the focus of care is gait training, 781.2 would be appropriate.

Take note: This scenario is a good example of when it's appropriate to code 781.2. In a recent frequently asked questions session, fiscal intermediary UGS said that gait abnormality is an appropriate diagnosis for a patient with a new hip or knee joint replacement who is favoring his affected leg. 

To support the use of 781.2, include the code for aftercare for joint replacement (V54.81) and the code that indicates that the patient's knee was the joint replaced (V43.65). You may also add V58.31 to show that the patient needs surgical wound dressing changes. Add the code for the diabetes, 250.00, as co-morbidity because it may affect the healing process of the wound.

Some coders may choose to sequence the diabetes code right after 781.2 for risk adjustment purposes and to list all of the V codes except for V57.1 at the bottom, and that's a good alternative, Mapili says.

You might also opt to exclude V58.31 for attention to surgical dressing because you are listing code V54.81 for aftercare of a joint replacement, and you might consider dressing changes integral to this aftercare. However, not all joint replacements would require dressing changes by the time the therapist becomes involved with the case in home care, Mapili says.

Some joint replacement patients have spent time in a skilled nursing facility before being discharged to home care. If this is the case, the wound is often healed and no longer requires dressing changes. Yet code V54.81 is still applicable.