Home Health ICD-9/ICD-10 Alert

Question: Our new patient was discharged from the hospital after an exacerbation of her asthma. She was sent home with new medications, including steroids, and breathing treatments. We will be monitoring her blood sugar and will need to teach everything to her elderly husband because she has Alzheimer's dementia. Her other diagnoses include controlled hypertension and history of pulmonary embolism. She is on Coumadin and is taken to the lab monthly for PT/INRs due to poor venous access. She also has GERD,which is managed by medication and diet, and a history of breast cancer. How should we code for her?

-- Vermont Subscriber

Answer: Code for this patient as follows, says Judy Adams, RN, BSN, HCS-D, COS-C, president and CEO

of Adams Home Care Consulting in Chapel Hill, N.C.:

M1020a: 493.90 (Asthma unspecified; unspecified);

M1022b: 331.0 (Alzheimer's disease)

M1022c: 294.10 (Dementia in conditions classified elsewhere without behavioral disturbance)

M1022d: V58.65 (Long-term [current] use of steroids)

M1022e: V12.51 (Personal history of pulmonary embolism)

M1022f: 401.9 (Essential hypertension, unspecified)

Other pertinent diagnoses: V58.61 (Long-term [current] use of anti-coagulants).

The primary focus of care for this patient is her asthma, Adams says. The patient has been prescribed new medication and continues her use of steroids to care for the asthma. Code for this condition with 493.90. Query the physician to find out whether the asthma is acute or chronic for more specificity and possible case mix points.

Mistake: You might be tempted to list a diabetes code for this patient because you will be monitoring her blood sugar, but diabetes isn't one of her diagnoses, Adams points out. This patient's blood sugar is being monitored because she has a higher risk of elevated blood sugar due to her steroid use.

The first secondary diagnosis you should list is Alzheimer's disease (331.0) followed by dementia (294.10); these conditions are the reasons you are doing teaching with the husband to look for signs and symptoms and to manage her care, Adams says. The patient cannot care for herself and it will be more difficult for her to tell you how she's feeling due to her Alzheimer's dementia.

Listing 294.10 indicates that the dementia is a manifestation of the Alzheimer's disease. It's important to list this diagnosis as well as the Alzheimer's diagnosis because you can't assume an Alzheimer's patient also has dementia, Adams says.

Next, list V58.65 to indicate that your patient is taking steroids. Watching for a risk of elevated blood sugar as a result of steroid use is a focus of your care, so it's important to include this V code, Adams says.

Report the patient's history of pulmonary embolism with V12.51. Past history with pulmonary embolisms leaves your patient at high risk of reoccurrence. She may not be able to tell you that she is running into difficulties that could indicate a reoccurrence of pulmonary embolism, so you need to watch her for signs.

Hypertension almost always impacts the plan of care, so list 401.9 as your last diagnosis code in M1022.

Additional diagnosis code V58.61 for long-term use of anti-coagulants adds clarity to this case, Adams says.While you're not drawing lab values, you will be monitoring the patient for any incidents of abnormal bleeding, etc.

Remember that with the exception of the Alzheimer's and dementia codes, secondary codes can be sequenced to best reflect the seriousness of the patient's condition and the sequencing is discretionary. You didn't code for gastroesophageal reflux disease (GERD), but if the GERD will impact the care -- for example if you'll be teaching regarding the pain of GERD versus the pain of pulmonary emboli -- then GERD may be coded, otherwise it is of mere historical significance and shouldn't be coded.