Home Health ICD-9/ICD-10 Alert

Hint: Code a symptom to avoid coding a disease or condition that has been resolved.

Knowing when to report a symptom and when to leave it off your list of diagnoses will save you time and make your coding more accurate.

Before you start thumbing through your ICD-9 manual to find the codes for all of your patient's symptoms, take a moment to determine whether it's appropriate to include them, experts advise.

The Centers for Medicare & Medicaid Services says home health coders are allowed to list a symptom code as the primary diagnosis in the following three situations:

(1)  when the medical diagnosis is not yet established;
(2)  when using a symptom code will keep you from using an outdated diagnosis; or
(3)  when the symptom code most accurately portrays the patient's condition.

The bottom line: So before you code a symptom, first determine whether it's appropriate to do so for your patient.

Code a symptom when a definitive diagnosis hasn't been determined. "Normally I try to be more specific than using the symptom codes, but sometimes you don't have a specific diagnosis; you just have symptoms that are odd," says Lucie Carter Lopez, RN BA, HCS-D, clinical supervisor with Interim Health Care in Fresno, CA.

Coding example: Physical therapy is providing gait training for a patient who is experiencing falls of unknown etiology. Code for this patient as follows, Sparkle Sparks, MPT, HCS-D, COS-C, with Redmond, WA-based OASIS Answers suggested during the Eli audio conference, "Overcome V57.1-itis And Other Common Therapy Coding Challenges."

• M0230a V57.1 (Other physical therapy);
• M0240b 781.2 (Abnormality of gait); and
• M0245a 781.2 (Abnormality of gait).

In this case, the symptom (abnormal gait) is the focus of your care, and no specific diagnosis has been determined for this patient.

Code a symptom to avoid coding a disease or condition that has been resolved. When providing aftercare for joint replacement surgery, you can't code a disease process such as osteoarthritis or degenerative joint disease "because it should have been corrected at the point of surgery," says Carter Lopez. In these situations, a symptom code can help justify the V code, which indicates the patient's care, she says.

Coding example: Nursing and physical therapy are providing care following a below knee amputation due to gangrene. The patient is receiving gait training as well as aftercare. Report the following codes, suggests Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX.:

• M0230a V58.49 (Other specified aftercare following surgery);
• M0240b V49.75 (Lower limb amputation status; below knee);
• M0240c 781.2 (Abnormality of gait); and
• M0245a 781.2 (Abnormality of gait).

To avoid coding a condition no longer present, code the symptom that is now the focus of care. The gangrene was resolved by the surgery, so reporting 785.4 (Gangrene) isn't appropriate for this patient.

Code a symptom when it is the best description of your patient's condition. Therapy is often only involved with a symptom, notes Sparks. In these cases, it's more appropriate to report the symptom rather than the disease.

When you have a symptom and a chronic long-term condition, you need to analyze the true reason or closest reason for the therapist being in the home, says Selman-Holman. "Is it for the gait issue alone or is it multiple therapy modalities that will be provided for the Parkinson's disease?" she asks.

Medicare calls this analysis the proximate condition vs. the underlying disease, Selman-Holman explains. Code the closest reason (the proximate condition) why the patient needs home care, she advises. In some cases, you may also list the underlying disease, but the disease wouldn't be listed in the primary or first secondary position.

Coding example: Your patient has Parkinson's disease. The only service you are providing is gait training for abnormality of gait.

• M0230a V57.1 (Other physical therapy);
• M0240b 781.2 (Abnormality of gait);
• M0240c 332.0 (Parkinson's disease); and
• M0245a 781.2 (Abnormality of gait).

The patient has Parkinson's disease, but your focus of care is the abnormal gait, so you should list this symptom code in M0240b and M0245a.

Protect yourself: Listing orthopedic code 781.2 for abnormality of gait in M0245a will net your agency 11 points. Don't be tempted to report the Parkinson's disease for this patient in M0245, advises Sparks. You could be accused of upcoding to score the 20 points this neurological code offers, she says. In this case, you're only addressing the abnormality of gait, so it's not appropriate to code for the Parkinson's disease in M0245.

Code the disease when multiple aspects will be addressed in the plan of care. When you are providing comprehensive care for multiple aspects of a disease or condition such as CVA, multiple sclerosis or Parkinson's disease, then it's appropriate to code for the disease as primary, says Sparks.

You don't have to have multiple disciplines involved to be covering multiple aspects of the disease, reminds Sparks. Nurses can do this, and so can physical therapists because they are trained in case management, she says. If documentation shows that they will be managing many aspects of the disease process, and not just the symptom, then report the disease, she advises. Clinical documentation is the key to supporting code selection.

Coding example: Nursing, speech therapy, and physical therapy are all dealing with different aspects of Parkinson's disease for this patient. List these codes, suggests Sparks:

• M0230a: 332.0 (Parkinson's disease);
• M0240b 781.2 (Abnormality of gait); and
• M0240c 787.2 (Dysphagia).

Tip: Look at plan of care to determine which of the therapies is more intensive and to see which symptom you should sequence first after the Parkinson's, suggests Sparks. Also look at severity rankings on the OASIS, she says. But remember, only code for the particular symptom if it is not integral to the condition, says Selman-Holman.