Home Health Coding and OASIS Expert

Remember to read the notes for increased accuracy.

Coding for aftercare may be a regular part of your day, but figuring out how to report infections and complications in ICD-10 isn’t yet part of your routine. Give yourself a jump-start on the transition by coding for these scenarios in ICD-10 before reading on to see the answers.

Scenario 1: Your new patient was referred to home health for care of an abdominal abscess associated with bariatric surgery a month ago due to streptococcus Group D resistant to vancomycin. He also has cellulitis of the abdomen. What ICD-10 diagnosis codes will you use for this patient?

Answer 1: List the following codes for this patient, says Judy Adams, RN, BSN, HCS-D, HCS-O, with Adams Home Care Consulting in Asheville, N.C.:

• K95.81 (Infection due to other bariatric surgery);

• B95.2 (Enterococcus as cause of disease classified elsewhere);

• Z16.21 (Resistant to vancomycin); and

• L03.311 (Cellulitis of abdominal wall).

You’ll find the code for infection due to bariatric surgery (K95.81) in the Alphabetic Index under complication; bariatric procedure, Adams says.

Under K95.81 in the Tabular List, you’ll see a note reminding you to use an additional code to specify the type of infection of organism. In your patient’s case, that’s Streptococcus Group D. You’ll find this code in the Alphabetic Index under streptococcus, streptococcal; group; D, as cause of disease classified elsewhere. Next, remember to code antibiotic resistance to help show the complexity of care.

The ICD-10 coding guidelines advise “It is necessary to identify all infections documented as antibiotic resistant. Assign a code from category Z16, Resistance to antimicrobial drugs, following the infection code only if the infection code does not identify drug resistance.” In this patient’s case, you’ll need to include Z16.21 to indicate resistance to vancomycin.

Look under Cellulitis; abdominal wall to find L03.311. The causative organism is not identified for the cellulitis. If the cellulitis is caused by the Enterococcus, then you’ll sequence this diagnosis second so that the organism code can be used to identify the cause of both infections.

Scenario 2: Your patient has extensive cellulitis of the abdominal wall due to an infected gastrostomy site. He had a feeding tube inserted four months ago due to carcinoma of the middle esophagus. The physician confirmed that the responsible organism for the infection is methicillin resistant Staph. aureus (MRSA). What diagnosis codes should you list for this patient?

Answer 2: List the following codes for this patient, says Adams:

• K94.22 (Gastrostomy infection);

• L03.311 (Cellulitis of abdominal wall);

• B95.62 (Methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere); and

• C15.4 (Malignant neoplasm of middle third of esophagus).

Sequence the infection of the gastrostomy first, Adams says. You’ll find your code (K94.22) when you look in the Alphabetic Index under Complications; gastrostomy; stoma; infection. A note under K94.22 in the Tabular List states to “Use an additional code to specify type of infection,” such as cellulitis of abdominal wall (L03.311) which you’ll list next.

Another instructional note that will guide your coding in this situation appears directly under the section “Infections of the Skin and subcutaneous Tissue (L00-L08),” Adams points out. The note states “Use additional code (B95-B97) to identify infectious agent.” In this case, the organism is Staph aureus (B95.62).

Follow this with a code to indicate your patient’s carcinoma. Look in the Neoplasm Table under esophagus; middle; malignant primary to find your code (C15.4).

Tip: Intraoperative and post procedural complications affecting the digestive system are included in Chapter 11 of the ICD-10 code set. ICD-10 moved many of the complications pertaining to certain body systems to that particular body system, Adams says. There are still many complications in the T chapter (Chapter 19).

Scenario 3: Your elderly patient was referred for post-operative management of a perineal abscess infected with E coli that was explored and drained 2 days ago. The wound is packed, and the dressing is changed daily by the patient’s wife. What diagnosis codes would you assign for this patient?

Answer 3: List the following codes for this patient, says Adams:

• K61.0 (Anal abscess) and

• B96.20 (Unspecified Escherichia coli [E. coli] as the cause of disease classified elsewhere).

This wound will remain an abscess until it heals. Although there is no note asking you to assign a code for the infection, you should add this detail when the information is known. 

Because the abscess is still present and infected, it’s not appropriate to include an ICD-10 code for dressing changes in this situation, Adams says.

Scenario 4: Your patient had a left below-knee amputation due to diabetic gangrene. You will be providing aftercare, observation and assessment, and dressing changes. How would you code for this patient?

Answer 4: List the following codes for this patient, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates, Code Pro University and CoDR — Coding Done Right in Denton, Texas.

Your focus of care for this patient is aftercare for his amputation, so Z47.81 is your primary diagnosis. The underlying diagnosis for your patient’s amputation is his diabetic gangrene. Because your patient had a diagnosis of diabetic gangrene, you can assume he has peripheral angiopathy, so you’ll list E11.52 across from M1021 in M1024 to describe the resolved, underlying reason for his surgery. This is an optional use of M1025 — codes placed in M1025 receive no payment and receive questionable risk adjustment, Selman-Holman says.

Next, you’ll list E11.51 because your patient still has diabetic angiopathy, but the surgery has eliminated his gangrene.

List Z89.512 to indicate that your patient had his left leg amputated below the knee.

And finally, you can list Z48.01 to indicate that you will be providing dressing changes for this patient because there is no complication present.

Scenario 5: Your patient had a left below-knee amputation due to diabetic gangrene. The amputation site is infected with MRSA and necrosed. Your orders are to provide care for the surgical wound including dressing changes. How would you code for this patient?

Answer 5: List the following codes for this patient, says Selman-Holman:

• T87.54 (Necrosis of amputation stump, lower left extremity);

• T87.44 (Infection of amputation stump, lower left extremity); and

• B95.62 (Methicillin resistant staphylococcus aureus infection as the cause of diseases classified elsewhere).

Your patient’s surgical wound is complicated in this scenario, so you won’t list an aftercare code. Instead, list codes to describe the necrosis and infection — T87.54 and T87.44. 

Follow this with B95.62 to indicate that the patient’s infection is caused by MRSA.

Don’t list the Z48.01 code for changing dressings because this patient’s wound is complicated, Selman-Holman says.