Home Health ICD-9/ICD-10 Alert

Published on Thu Oct 20, 2011 PDF

Question: Our patient is home after a coronary artery bypass graft (CABG) for coronary atherosclerosis (CAD) of his native artery. He needs continued observation and assessment of the surgical incision on his leg with three areas of incisional separation but no signs or symptoms of infection. He is a little weak but no longer has chest pain. He has diabetes with fasting blood sugar of 109 and diabetic peripheral angiopathy. He also has benign localized prostatic hyperplasia with urinary retention and frequent urinary tract infections and will be scheduled for a transurethral resection of the prostate soon. We are providing skilled nursing and physical therapy. How should we code for this patient?

Maryland Subscriber

Answer: Code for this patient as follows:

• M1020a: 998.32 (Disruption of external operation [surgical] wound);
• M1022b: 414.01 (Coronary atherosclerosis of native coronary artery);
• M1022c: 250.70 (Diabetes with peripheral circulatory disorders; type II or unspecified type, not stated as uncontrolled);
• M1022d: 443.81 (Peripheral angiopathy in diseases classified elsewhere);
• M1022e: 600.01 (Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms [LUTS]); and
• M1022f: 788.20 (Retention of urine, unspecified).

You'll code the surgical wound with the incisional separation as external disruption with 998.32. Be sure to check this with the physician before coding complications.

Follow the complicated wound code with the CAD diagnosis (414.01) because in this case the CABG treats the disease but doesn't cure it.

Next, list 250.70 for diabetes with a circulatory condition, and pair this with 443.81 to indicate your patient's diabetic manifestation -- diabetic peripheral angiopathy.

The notes under 600.01 ask that you list an additional code to identify the LUTS, in this case retention of urine (788.20).