How to Code an Infected Hip Joint Replacement in ICD-10
The patient is admitted to home health following an infection of her right hip replacement. She is receiving IV vancomycin for the infection, and nursing will be drawing vanc peak and trough levels as well as completing wound care.
M1021a – Infection and inflammatory reaction due to internal right hip prosthesis, initial encounter T84.51XA
M1023b – Encounter for adjustment and management of vascular access device – Z45.2
M1023c – Encounter for therapeutic drug level monitoring – Z51.81
M1023d – Long term (current) use of antibiotics – Z79.2
The hip replacement is complicated, so an aftercare code is not appropriate. Because the infection is being actively treated with IV antibiotics, the seventh character of “A” is appropriate in home health. Also because the right hip joint is indicated in the complication code, a status code is not necessary. The attention to IV is captured by the use Z45.2. The drawing for vanc peak and trough levels is indicated by the use of Z51.81 followed by the antibiotic code of Z79.2.