Question: Our new patient was referred to home care for aftercare following coronary artery bypass surgery due to coronary artery disease. She has co-morbidities of Type II diabetes, peripheral neuropathy, hypertension, and left-sided hemiplegia secondary to a stroke more than 20 years ago. She is on Amitryptyline and states that this effectively controls her depressive symptoms; her PHQ-2© score is 0. How should we code for this patient?
Delaware Subscriber
Answer: List the following codes for this patient:
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M1020a: V58.73 (Aftercare following surgery of the circulatory system, NEC);
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M1022b: 414.00 (Coronary atherosclerosis of unspecified type of vessel, native or graft);
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M1022c: 250.00 (Diabetes mellitus without mention of complication; type 2 or unspecified type, not stated as uncontrolled);
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M1022d: 356.9 (Hereditary and idiopathic peripheral neuropathy; unspecified);
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M1022e: 401.9 (Hypertension; unspecified);
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M1022f: 438.20 (Late effects of cerebrovascular disease; hemiplegia affecting unspecified side); and
Other diagnoses: V45.81 (Aortocoronary bypass status).
Answer: You’ll want to query the physician for more information about this patient before coding so you can choose the most accurate codes.
To begin with, nowhere in this patient’s chart is there a documented diagnosis of depression, points out Beth Johnson, MBA, BSN, RN, CRRN, HCS-D, HCS-O, with Johnson, Richards & Associates, in Brighton, Mich. Despite the fact that she is on an antidepressant and states that she has depression, you can’t include this diagnosis, unless the diagnosis is verified with the physician and the doc adds it to the list of diagnoses, she says.
Caution: Note that 311 (Depressive disorder, not elsewhere classified) and diagnoses from the 296.xx (Episodic mood disorders) category are all case-mix and therefore add to reimbursement received if the patient’s payer requires a HHRG score. But before you list one of these diagnoses, you must also make certain that it truly does impact the care your agency will provide.
You’re providing aftercare following this patient’s bypass surgery, so V58.73 is your principal diagnosis. Follow this with 414.00 because the surgery doesn’t eliminate her CAD.
Tip: If your patient has never had another bypass, then common sense indicates that the CAD involved the native coronary arteries. But if the documentation is not present from the physician, you’re safe with choosing 414.00, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates and CoDR — Coding Done Right in Denton, Texas.
Next, you should code for her relevant co-morbidities. She has diabetes and peripheral neuropathy, but you cannot assume these conditions are an etiology and manifestation pair unless this relationship is specifically documented, Johnson says. If the physician confirms that her neuropathy is due to her diabetes, you would code for these conditions with 250.60 (Diabetes with neurological manifestations; type 2 or unspecified type, not stated as uncontrolled) and 357.2 (Polyneuropathy in diabetes).
Include a code for this patient’s hypertension next. You don’t have an indication as to whether your patient’s hypertension is benign or malignant, so you’ll need to report unspecified code 401.9.
Follow this with 438.20 to indicate that your patient is experiencing hemiplegia as the late effect of a stroke. The 438.20 code is not a great choice for specificity. But you can’t make any assumptions about which hand is dominant for this patient, Johnson says. To list a more specific code such as 438.21 (Late effects of cerebrovascular disease; hemiplegia affecting dominant side) or 438.22 (Late effects of cerebrovascular disease; hemiplegia affecting nondominant side), you should ask the clinician for more information.
Tip: When coding for hemiplegia, the side affected is based on the patient’s hand dominance prior to the CVA, since many patients learn to become proficient in use of the non-affected non-dominant side after a CVA, Johnson says.
Finally, include status code V45.81 to indicate that your patient had coronary artery bypass surgery.
In ICD-10 for this patient, you would list the following codes:
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M1021a: Z48.812 (Encounter for surgical aftercare following surgery of the circulatory system);
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M1023b: I25.10 (Atherosclerotic heart disease of native coronary artery without angina pectoris);
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M1023c: E11.9 (Type 2 diabetes mellitus without complications);
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M1023d: G62.9 (Polyneuropathy, unspecified);
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M1023e: I10 (Essential [primary] hypertension);
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M1023f: I69.354 (Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side); and
Other diagnoses: Z95.1 (Presence of aortocoronary bypass graft).
Once again, an aftercare following surgery of the circulatory system is your first-listed code.
Follow this with codes for your patient’s CAD, diabetes, and peripheral neuropathy. Note that I25.10 indicates the native coronary arteries were affected by the arteriosclerosis. There is no choice for unspecified vessel, native or graft in ICD-10. “You may assume if the physician didn’t document a specific type of graft involved or a transplanted heart, etc. that the vessels involved are those the patient was born with — the natives,” Selman-Holman says.
In ICD-10, you’ll no longer have the option to indicate whether hypertension is benign or malignant, so I10 will be your code for primary hypertension.
When it comes to determining whether to report a side as dominant or nondominant for a patient with hemiplegia as the sequela of a stroke, you’ll get some new guidelines in ICD-10. When the documentation indicates the affected side, but doesn’t tell you whether it’s the patient’s dominant or nondominant side, base your choice on the following guidance:
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For ambidextrous patients, the default choice is dominant.
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If the left side is affected, the default choice is non-dominant.
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If the right side is affected, the default choice is dominant.
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