Category Archives: ICD 9

Coding Coronary Artery Disease (CAD)

Coding Coronary Artery Disease (CAD) may seem straightforward but, there is specific information needed before you can accurately assign a CAD code. Carefully review the patient’s chart to determine if CAD is affecting the native arteries or grafted arteries. If the patient has had a CABG in the past, there is a chance that CAD is present in the grafted arteries rather than in the native arteries. If this is the case assign a code from the range  414.02-414.05. Also remember to assign  V45.81 CABG Status to show the patient’s surgical history and extent of CAD. If the patient does not have a history of a CABG surgery, then you can assign code 414.01 CAD of native vessels. Always check your documentation before assigning an unspecified CAD code.

Late Effects of Poliomyelitis: Let’s Clear Up the 138 Confusion

Coding Late Effects of Acute Poliomyelitis

Acute poliomyelitis is a diagnosis we do not code very often but we do need to watch out for its residual deficits.  Acute poliomyelitis is a disease of the anterior horn motor neuron of the spinal cord and brain stem caused by poliovirus.

A patient who has a residual deficit of poliomyelitis will be coded using the 138 code, late effects of acute poliomyelitis, rather than a code from the 045 category.  The residual deficit will be coded first followed by the late effect code.  The only time this would be different is if the residual is a manifestation code in which the late effect code would precede the residual (manifestation) code, see example below.

Patient admitted into home care for PT to evaluate and treat patient for strengthening due to diagnosis of osteopathy of leg resulting from poliomyelitis.

V57.1    Other, physical therapy

138        Late effects of acute poliomyelitis

730.76  Osteopathy resulting from poliomyelitis

ICD 10:  B91

Therapeutic Drug Monitoring: V58.83

Many times, clinicians have orders to draw labs to monitor drug levels, in order to capture the lab draws for drug monitoring, V58.83 Encounter for Therapeutic Drug Monitoring is used. When listing V58.83 an additional code from V58.61 – V58.69 should be used to indicate the type of drug that is being monitored.  Encounter of Therapeutic Drug Monitoring (V58.83) should not be used as a primary diagnosis for a home health patient. V58.83 code is not used for simple medication management nor for filling a medication box.  Coders should only use V58.83 therapeutic drug monitoring when the clinician is assessing the effectiveness of a medication through lab information.

Example 1:  A patient has a diagnosis of DVT and is on Coumadin therapy, skilled nurse is drawing blood for PT/INRs.

M1020a:DVT – 453.40

M1022b:Encounter for drug monitoring – V58.83

M1022c: LT use (current) anticoagulants – V58.61

Rationale: DVT is listed as the primary diagnosis as this is the diagnosis requiring Coumadin. Since the nurse is drawing blood for PT/INRs, V58.83 Encounter for Therapeutic Drug Monitoring is listed, as well as the type of drug being monitored, in this case Coumadin, an anticoagulant.

Example 2:  A patient has a diagnosis of acute osteomyelitis of the foot. The patient has a PICC line in which vancomycin is being administered for 6 weeks.  Skilled nurse to draw labs weekly for vanco trough levels.

M1020a: Acute Osteomyelitis of foot – 730.07

M1022b: Therapeutic drug monitoring – V58.83

M1022c:  LT use (current) antibiotics – V58.62

M1022d: Attention vascular device – V58.81

Rationale: Acute Osteomyelitis of foot is listed as the primary diagnosis as this is the diagnosis requiring Vancomycin. Since the nurse is drawing blood for troughs, V58.83 Encounter for Therapeutic Drug Monitoring is listed, as well as the type of drug being monitored, in this case Vancomycin, an antibiotic.

Long-term (current) drug use codes V58.61- V58.69 can only be used as secondary codes and should not be used for simple medication monitoring.  The words “long term” can be a little misleading as there is no official definition for long term.   These codes are to be used if the medication shows to be an important aspect of the plan of care or if the coding guidelines require the use of the code,  e.g. insulin use for a diabetic patient.

V58.61 LT use of anticoagulants (Coumadin, Warfarin, Enoxaparin, Pradaxa)

V58.62 LT use antibiotics (Vancomycin, Cubicin)

V58.63 LT use antiplatelets/antithrombotics (Plavix)

V58.64 LT use non-steroidal anti-inflammatories (NSAID)

V58.65 LT use steroids (Prednisone)

V58.66 LT use aspirin (ASA)

V58.67 LT use insulin (Levemir, Lantus)

V58.68 LT use bisphosphonates *NEW* (Reclast, Fosamax, Boniva, Actonel)

V58.69 LT use of other medications (use for B12, Dilantin, Digoxin)


Coding Osteoarthritis

Osteoarthritis  (OA) is a joint inflammation that results from cartilage degeneration. Degeneration occurs due to rubbing of the joint surfaces, causing a wearing away of the tissues. Osteoarthritis (also known as degenerative arthritis, degenerative joint disease, and osteoarthrosis)  is the most common type of arthritis which usually occurs in the hands, knees, hips, and spine.

Osteoarthritis of most sites, except the spine, is assigned to ICD-9-CM category  Osteoarthrosis and allied disorders (715). Osteoarthritis of the spine is assigned to category Spondylosis and allied disorders (721). The specific code assignment depends on the site of the spine involved (example cervical, thoracic, lumbar) and if myelopathy is present. In category 715, the fourth-digit code assignment identifies whether the osteoarthritis is generalized or localized and the fifth-digit code assignment identifies the specific site involved.

Generalized osteoarthritis (code 715.0x) affects many joints, while localized osteoarthritis affects the joints of one site.

Localized osteoarthritis can be further broken down into two other categories:

  • Primary osteoarthritis (715.1x),  is localized osteoarthritis not resulting from injury or disease, is mostly a result of natural aging of the joint.
  •  Secondary osteoarthritis (715.2x)  is due to another disease or condition. Conditions that can lead to secondary osteoarthritis include obesity, repeated trauma or surgery to the joint structures, gout, diabetes, and other hormone disorders.

If the localized osteoarthritis is not specified as primary or secondary, code 715.3x is assigned. Bilateral involvement of the same site is still considered localized and is included in the fifth digit for the site. Code 715.9x is assigned when it is not specified as generalized or localized.

Coding DVTs

According to the A.D.A.M. Medical Encyclopedia, a deep vein thrombosis (DVT) is the formation of a blood clot in a vein that is deep inside a part of the body, usually the legs.  Deep venous thrombosis (DVT) mainly affects the large veins in the lower leg and thigh. The clot can block blood flow and cause swelling and pain. When a clot breaks off and moves through the bloodstream, this is called an embolism. An embolism can get stuck in the brain, lungs, heart, or other area, leading to severe damage.

Acute vs Chronic DVT
A DVT is considered acute when the occlusion is obstructing blood flow and causes pain and swelling. DVTs are labelled as chronic when the DVT exists for longer than 10 to 14 days. If documentation does not indicate whether the DVT is acute or chronic, code the DVT as acute.
Postoperative DVT
If a DVT is documented as postoperative or iatrogenic, assign code 997.2 Peripheral Vascular Complication, followed by a code for the DVT.
Symptoms
Swelling
Pain
Discoloration (redness) and warmth around the affected area.

The symptoms listed above are also associated with thrombophlebitis (inflammation of the vein with a blood clot). The physician may use the terms “DVT” and “thrombophlebitis” interchangeably. According to the AHA Coding Clinic for ICD-9-CM, if both thrombophlebitis and DVT are documented, only a code for the thrombophlebitis is assigned (category 451). (AHA Coding Clinic for ICD-9-CM, 1992, first quarter, pages 15-16).

Treatment
Anticoagulants, such as Coumadin and Pradaxa, are the main medications used to treat DVTs. These medications are also known as “blood thinners” because they decrease the blood’s ability to clot. Patients are usually on anticoagulant therapy for three to six months-these medications prevent other clots from forming, they do NOT resolve the existing clot. Assign code V58.61 as a secondary diagnosis if the patient is on an anticoagulant. If the DVT is resolved, you will report code V12.51 Personal History of Venous Thrombosis and Embolism. 
PT/INR (Prothrombin time test/International Normalized Ratio) is blood test used to monitor to the effectiveness of anticoagulants in the blood. In order to code PT/INRs correctly, you should report V58.83 Drug Monitoring, followed by V58.61 Long-Term Anticoagulant Use. These codes should be reported together only when SN is performing this test.

Beware of Epilepsy Coding

March is National Epilepsy month, this is a great time to review seizure coding!

When a physician documents the following regarding seizures, it should be coded as:

  • “seizures,” “repetitive seizures,” “convulsions,” “repetitive convulsions,” or “single seizure,” coders should report symptom code 780.39
  • “seizure disorder,” coders should report code 345.9x (epilepsy)
  • “recurrent” coders should also report a code from category 345.8x
*If the documentation states “disorder” please note that you will report the 345.9x code*

According to PubMed Health, epilepsy is “is a brain disorder in which a person has repeated seizures (convulsions) over time. Seizures are episodes of disturbed brain activity that cause changes in attention or behavior.”

Visit the Epilepsy Foundation Web site at www.epilepsyfoundation.org for more information on epilepsy.

Coding Late Effects of CVA

Cerebrovascular Accident (CVA) is more commonly known as stroke. CVAs occur when there is a disruption of blood flow to the brain. Survivors of CVAs often suffer from disabilities (late effects or residuals) that can impact physical, psychological and social aspect of their lives.

Generally, late effects are coded by listing the nature of the late effect followed by the cause of the late effect. However, coding the late effect of a CVA is an exception to this rule.

Cerebrovascular Accident  (CVA) (430 – 437) is reserved for acute care settings only.  Home health agencies routinely manage the neurological deficits or disabilities created by the CVA.  Agencies do not treat the patient during the onset/evolution stage of the CVA.

Category 438  Late effects of cerebrovascular disease can be used to report CVA’s in Home Health. If a patient does not exhibit any residuals, late effects, or sequelae of a CVA, then the coder should use the History of CVA/TIA code V12.54, if applicable.

Many codes in Category 438 are combination codes, therefore,  one code is used to describe the late effect. The combination codes in this category include both the nature of the late effect and the late effect.

  • 438.0 Cognitive deficits
  • 438.1x Speech and language deficits
  • 438.2x Hemiplegia/hemiparesis
  • 438.3x Monoplegia of upper limb
  • 438.4x Monoplegia of lower limb
  • 438.5x Other paralytic syndrome

Example: A patient has hemiplegia of the non-dominant side and aphasia as a result of a recent CVA.
438.22  Late effect of CVA with hemiplegia non-dominate side.
438.11   Late effect Aphasia.

Category 438 also includes CVA late effect codes that require additional codes to further explain the late effect.

  • 438.8x Other late effects of cerebrovascular disease

Example: The patient has dysphagia, oropharyngeal phase as a result of a CVA two years ago.
438.82 Dysphagia (late effect of CVA)
787.23 Dysphagia, pharyngeal phase

When Category 438 does not list the patient’s residual condition, use code 438.89 along with a second code to further describe the patients late effect of the CVA. 

Example: The patient has generalized muscle weakness as a result of a CVA.
438.89 Other late effects CVA
728.87 Muscle Weakness (generalized)

Keep in mind, CVAs are a medical emergency, this is why acute CVAs (categories 430 – 437) can only be used in home care in limited circumstances, there has been no infarct.