Home Health ICD-9/ICD-10 Alert

Question: Our new patient is being admitted for surgical aftercare due to bladder cancer that resulted in a bladder resection with resulting urostomy. He also has diabetes and generalized weakness. He has always taken an oral hypoglycemic but since surgery has been on a sliding scale for insulin. Therapy will be seeing the patient for his weakness but nursing is primary for aftercare. He will begin chemo after incision has healed.

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

• M1020a: V58.42 (Aftercare following surgery for neoplasm);

• M1022b: 188.9 (Malignant neoplasm of bladder, part unspecified);

• M1022c: 728.87 (Muscle weakness [generalized]);

• M1022d: 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled);

• M1022e: V55.6 (Attention to artificial opening of urinary tract);

• M1022f: V58.67 (Long-term [current] use of insulin); and

• Other pertinent diagnoses: V45.74 (Acquired absence of organ other part of urinary tract).

The primary reason your patient is being admitted to home care is aftercare for his cancer surgery, so V58.42 is your principal diagnosis. Follow this with 188.9 to specify that he has bladder cancer.

The surgery resulted in your patient's urostomy, so code for this next with V55.6 as it will be one of the conditions for which your agency provides care. The sequencing of this code as secondary is discretionary, but it also a case mix code.

Your therapists will be addressing the patient's generalized muscle weakness, so you should be sure to report this diagnosis. Your patient has muscle weakness, but there is no indication that it affects one particular muscle group, so 728.87 is the correct code. Note: Never sequence a symptom associated with cancer before the cancer code itself.

Your patient doesn't have any documented diabetic manifestations, but he is on a sliding scale for insulin. You'll want to list 250.00 to indicate the diabetes diagnosis and follow this with V58.67 to show that he is taking insulin.

Finally, list status V code V45.74 to document his bladder resection. This code can come last in the list, leaving room in the first six diagnosis code slots for the diagnoses that best describe the care you will be providing.