Responses for 12/1 and new scenarios/information for 12/8/14

Responses to scenarios for 12/1/14


Could you explain how to use V54.81 and V54.82 when coding patients who have had a joint replacement?

V54.81, aftercare following joint replacement, has been commonly used for patients who have received a joint prosthesis or a repair of a joint prosthesis.  V54.81 best reflects the type of care that is required following a joint replacement either because of OA or due to a fracture. This code also is used for patients who require repair of a prosthesis that may involve modification or partial repair without removing the entire prosthesis. The tabular includes the instructional note to add an additional code to identify the joint replacement site from V43.6x, Organ or tissue replaced by other means, joint.

In 2011, the Coordination and Maintenance Committee determined that a new code was needed for situations in which a prosthesis must be explanted and replaced with a spacer or replaced with another prosthesis in a staged operation because the aftercare for these patients is more complex than following an original joint replacement. Thus, V54.82 was implemented October 1, 2011, for use with patients who are seen for aftercare following explantation of a joint prosthesis. Coding clinic, an official resource for coding information, offered some limited clarification on the use of this code in the Fourth Quarter 2011 (pp 156-158): ” Code V54.82, Aftercare following explantation of joint prosthesis, has been created to allow the reporting of patient encounters for aftercare following the removal of joint prosthesis. The aftercare includes encounters for joint replacement insertion surgery where it was necessary to stage the procedure or for the joint prosthesis insertion following a prior explantation of the prosthesis. There may be a medical need to remove an existing joint prosthesis (e.g., due to infection or other problem), but it may not be possible to replace the prosthesis at the same encounter, thereby requiring a return encounter to insert a new prosthesis. This code may be used with the appropriate code from subcategory V88.2x, acquired absence of joint, to specifically identify the joint.”


This elderly woman was being treated for her right eye age-related cortical cataract at this day-surgery center. After the procedure was complete, the patient suffered a postoperative hemorrhage of the eye. This was addressed by the surgeon. What is the correct code(s)?

H25.011, Cataract (cortical) (immature) (incipient), age-related, See Cataract, senile, cortical

*******H59.311, Hemorrhage, postoperative.  See Complications(s) (from) (of), post procedural, hemorrhage (hematoma) (of), eye and adnexa, following ophthalmic procedure

*******Y92.530, Index to external causes, Place of occurrence, outpatient surgery center.

****** The two codes (hemorrhage and external cause code) will not be used in home care, but in the setting of occurrence only.

Complication codes in ICD-10-CM are differentiated between intra-operative and postoperative. In this case, the primary diagnosis is the cataract and the postoperative complication is listed as sedentary. A place of occurrence code can be added to indicate that this occurred in a day-surgery center. This code includes an outpatient surgery center connected with a hospital. Per coding guideline I.C.19.g.4, an external cause of injury code is not required as the complication code has the external cause included in the code.


M1016 diagnoses are limited to diagnoses that have undergone medication changes within the last 14 days. True or False?

FALSE!  The diagnoses assigned to M1016 should be new conditions or existing conditions that have exacerbated within the last 14 days. “Medical regimen change” is not limited to changes in medications. The conditions listed in M1010 (inpatient diagnoses) also may include those where there has been a change in specific treatment parameters or a change in health services (i.e. the patient will be receiving dialysis three times a week instead of four times a week).

Like M1010, the use of symptoms should be minimized. Diagnoses assigned to M1016 should be coded to the highest level of specificity. Conditions assigned to M1016 may or may not be the same as those in M1010 (inpatient diagnosis) or M1020 (primary) / M1022 (other diagnosis).

New guidance: The issue of assigning “improved” conditions in M1016 was addressed by CMS in category 4 of the OASIS-C1/ICD-9 consolidated Q&As (June 2014). The Q&A states: “If at any time in the last 14 days the patient requires a medical or treatment regimen change due to de elopement of a new condition or lack of improvement or worsening of an existing condition, the diagnosis should be reported in M1016, even if the condition also showed improvement or stabilization during that time, or is improved at the time of the SOC/ROC.”

The CMS response regarding the assignment of improved conditions in M1016 means that it is acceptable to code these conditions in M1016 when the condition still exists and is relevant to the care of the patient. Review this phrase in the guidance: “the diagnosis should be reported in M1016, even if the condition also showed improvement or stabilization during that time, or is improved at the time of the SOC/ROC.”

New scenarios for 12/8/14


This 88-year-old gentleman is receiving home care for his coronary artery disease and the cardiac pacemaker placed during his hospitalization last week. He continues to gain strength but requires wound checks, dressing changes, and medication management ongoing. Assign the correct diagnosis codes.


What is included in an aftercare code such as aftercare of surgery?  Monitoring incisions? Wound care? If so, why do we also use the wound care V58.3x series of codes for non-complicated wounds?


M1033 (Risk for hospitalization)

The item number for M1032 (Risk for hospitalization) has been changed to M1033.  The item has been revised based on clinical findings that have been shown to impact a patient’s risk for hospitalization. The number of options has expanded from seven to ten. Response options have also been reordered based on the timeframe in which an event occurred or how long symptoms/issues were exhibited. The changes to the item have improved specificity. Added risk factors now include:

  • Unintentional weight loss of 10 pounds or more in the past 12 months
  • Multiple emergency department visits (2 or more) in the last 6 months
  • Reported or observed h history or difficulty complying with any medical instructions in the past 3 months
  • Currently reports exhaustion

The number of medications qualifying as a risk factor in M1033 remains five. Specific time periods have been added to all risk factors (for example: Decline in mental, emotional or behavioral status in the past three months).

OASIS C1/ICD-9 goes into effect January 1, 2015.  The M0090 date will determine which OASIS you will be using during January. Stay tuned for additional information soon!

Let me know if you have any questions or suggestions for posts.


Up ↑

%d bloggers like this: