Eli's Rehab Report

Published on Thu May 24, 2012 PDF

Never list an acute fracture code in M1020.

When you're providing routine aftercare for home health patients, you'll need to list the V code that best describes your patient's situation. But each aftercare V code has quirks you must be aware of before you can nail down the right one.

Know When to List These Common Aftercare Codes

Your patient had a coronary artery bypass graft (CABG) due to coronary artery disease (CAD). You would code for CAD with a 414.x (Other forms of chronic ischemic heart disease) code. When the focus of care is your patient's routine recovery from a surgical procedure, you'll most often look to the aftercare V codes in the V58.7x (Aftercare following surgery to specified body systems not elsewhere classified) subcategory, says Trish Twombly, BSN, RN, HCS-D, CHCE, COS-C, HCS-O director of coding with Foundation Management Services in Denton, Texas.

Simply locate the correct code for the underlying reason for the surgery and match it to the range of conditions listed in the "Conditions classifiable" note to find the right V58.7x code. Other common aftercare codes include:

Trauma: If your patient has a leg amputated due to peripheral vascular disease (443.x) V58.73 is your aftercare code as well. But if the leg was amputated due to trauma, and your patient had the same surgery, the aftercare code would be V58.43 (Aftercare following surgery for injury and trauma) because the surgery was due to injury or trauma. "Two patients with the same surgery could have two different aftercare codes," Twombly says. You'll list aftercare code V58.43 (Aftercare following surgery for injury and trauma) when the surgery is for a traumatic injury that would classify to diagnoses from the 800-999 (Injury and poisoning) categories.

Exclusion: Code for trauma fractures with V54.1x (Aftercare for healing traumatic fractures).

Neoplasms: When your patient requires aftercare for surgery to treat a neoplasm, report aftercare code V58.42 (Aftercare following surgery for neoplasms). This V code applies to all the codes in Chapter 2 of your tabular list codes 140-239.

Fractures: Choose your fracture aftercare code depending on whether the fracture was due to trauma (V54.1x), was a pathologic fracture (V54.2x), or was repaired by a joint replacement (V54.81).

Caution: Don't list an acute fracture code in M1020/M1022 because these acute codes are reserved for active treatment (provided by the hospital, a physician or the emergency department). Instead, you can list the acute fracture code in M1024. But you'll only earn case mix points if the diagnosis is included in the Ortho 1 or Ortho 2 case mix lists and the patient is receiving either IV or parenteral therapy in the home (M1030 = 1 or 2) or has a pressure ulcer.

Joint replacements: Code for joint replacements with two codes -- V54.81 (Aftercare following joint replacement) followed by the appropriate V43.6x (Organ or tissue replaced by other means; joint) code for the location.

Rehabilitation: If you're providing therapy-only for a patient following surgery, look to the codes from the V57.x (Care involving use of rehabilitation procedures) series, says Jennifer Warfield, RN, BSN, HCS-D, COS-C, education director with PPS Plus Software in Biloxi, MS.

Use V57.1 (Other physical therapy) as the principal diagnosis when physical therapy only is on the initial plan of care, there is no intention to add nursing, and the focus of the therapist is to rehab the patient to a former functional level.

Look to V57.89 (Multiple training or therapy) for rehab cases that involve more than one therapy discipline such as physical therapy and occupational therapy, but again, only if the focus is one of rehabilitation.

Use additional code: Follow the V57.x code with the code for the underlying condition being addressed such as gait abnormality, or joint replacement, Warfield says.

If therapy does not meet the criteria for being the primary diagnosis -- for example, when nursing is in the plan of care -- the V57.x code should not be used at all.

Caution: The V57.x codes can only be listed in M1020 and apply only when therapy is the sole discipline in the home, Warfield says. "If nursing is in for skilled visits, V57.x can't be primary." Instead, list the diagnosis driving the need for both disciplines.

Tip: There are times when therapy is all that is ordered at start of care (SOC) and it is appropriate to have the therapist complete the initial and comprehensive assessment. However, "I'm asked all the time 'What if the therapist identifies a need for nursing during the assessment and we get orders to add nursing?'" 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. "My answer is that if you have orders within the SOC timeframe for nursing, then you should not use the V57.x code." Instead, for the principal diagnosis, list an appropriate condition code to indicate why the patient is receiving home health.

Don't Overreact to V57.x and Nursing

Although it's true that you can't list a V57.x code when your patient is receiving skilled nursing visits, some coders take this ban a little too far. It's ok for the therapist to open a therapy-only case and do the start of care (SOC) OASIS, but many agencies only allow nurses to open a case, Warfield says. "If the nurse opens a therapy-only case, you have an unbillable nursing visit, but you can still list a V57.x code for this patient."

Reminder: Home health coding is based on skilled visits -- the RN making a non-billable visit to complete the OASIS should not be considered in your coding decision.

Mistake: When deciding whether to use a V57.x (Care involving use of rehabilitation procedures) code, don't start by tallying up which discipline has more visits -- nursing or therapy. The V57.x codes are appropriate only in therapy-only situations. For multi-discipline cases, look to the aftercare codes or the condition codes.

Example: You are providing aftercare following a knee replacement. Nursing will make three visits to see the patient; physical therapy will visit three times a week for three weeks to address the patient's abnormal gait.

For this multi-disciplinary case, list V54.81 (Aftercare following joint replacement) first, followed by V43.65 (Organ or tissue replaced by other means; joint; knee). Follow these codes with 781.2 for abnormality of gait if you feel including this symptom adds to the picture of your patient's condition. Sequencing for additional V codes is discretionary so you can also place V43.65 lower on your list if the patient has other conditions.