Inpatient Facility Coding & Compliance Alert

Question: I’m coding the start of care (SOC) on a patient who was admitted to our home health agency for physical therapy (PT) following surgery to replace a broken prosthetic hip joint. She uses oxygen intermittently for her COPD and has GERD, which is well-controlled with medication and diet. My co-worker and I have a difference in opinion on how to code this. How should this patient be coded?

Arkansas Subscriber

Answer: Code this patient, as follows, says Sharon Molinari, RN, HCS-D, HCS-O, a home health consultant and educator in Las Vegas, Nevada:

• M1020a: V57.1 (Care involving other physical therapy);
• M1022b: V54.82 (Aftercare following explantation of joint prosthesis);
• M1022c: 496 (Chronic airway obstruction, not elsewhere classified);
• M1022d: V43.64 (Hip joint replacement); and
• M1022e: V46.2 (Dependence on supplemental oxygen).

The encounter for physical therapy is your primary diagnosis for this patient, because this is a PT-only case, Molinari says. Coding guidelines state that you must list V57.x as the principal/first-listed diagnosis when the purpose for the admission/encounter is rehabilitation. You’ll report the code for the condition for which the service is being performed as an additional diagnosis.

In this scenario, the underlying condition is aftercare following removal of the joint prosthesis and insertion of the new one. Assign V54.82 when a prosthesis has been removed or when there has been a partial or total revision, in the absence of a complication. But if the joint replacement and/or revision are complicated, code the complication and not V54.82.

Codes V57.x and V54.x are not eligible for case mix points (only V54.1 and V54.2 are, when paired with an eligible fracture code), Molinari says. However, if a V code replaces a resolved case mix diagnosis that’s relevant to the plan of care, you can report this code in M1024 for potential risk adjustment, but it will not be awarded case mix points. In this case, the underlying cause for the surgery, the broken prosthetic joint, 996.43, is not case mix so it’s not appropriate to report in M1024.

COPD is a co-morbidity that you should always code, because it may impact, or be impacted by, the patient’s plan of care, Molinari says. Code chronic COPD, 496, when the physician documentation does not state that the COPD is exacerbated or decompensated or when he doesn’t indicate a specific type of COPD.

You should code for relevant co-morbidities on therapy-only cases, Molinari says. The therapist should be aware of these conditions and should monitor the impact of them on the patient’s rehabilitation prognosis and, also, observe for possible effects, which may occur as a result of the therapy regimen.

GERD is a case mix co-morbidity that you should not code when it’s stable and has no direct impact on the plan of care. If you do code for it, make certain that details regarding how it impacts the care plan are documented, and that it is addressed in the plan of care and visit notes.

List a V43.6x code to indicate the joint replaced. Report this code with any joint replacement, even if complicated. This is an exception to the rule that status codes are only appropriate when there is no complication.

Because V43.64 and V46.2 are status codes, their sequencing is discretionary. So, you can list them after the numeric codes. This is preferable, because they don’t impact risk adjustment, reimbursement, or patient outcomes.