Home Health ICD-9/ICD-10 Alert

Trend alert: Watch for RHHIs to link V57.x with OASIS functional scores.

If your agency is like many home care providers, codes from the V57.x series (Care involving use of rehabilitation procedures) are among your most-reported primary diagnoses. But despite their popularity, there's a hot debate over when to use these codes.

The V57.x series codes are the most controversial codes right now, says Trish Twombly, RN, BSN, HCS-D, director of coding with Foundation Management Services in Denton, TX. There are two camps regarding the use of these codes, she says. The first says you should list a V57.x code in M0230 only for therapy-only cases. The other camp's thinking isn't quite so purist -- it advocates using the V57.x series when the focus of care is rehab therapy.

"I guess I have one foot in each camp, waiting on clarification from the Centers for Medicare & Medicaid Services (CMS)," Twombly says. She uses the following framework to make the decision whether to use a V57.x code:

Example: Your patient is recovering from a knee joint replacement. Both therapy and nursing are seeing the patient, but the focus of care is therapy due to the patient's gait disturbance. Nursing will provide Lovenox injections and follow-up lab work as well as removing the staples.

Solution: Put V54.81 (Aftercare following joint replacement) in M0230. Then list the reason that therapy is going to the home, such as 781.2 (Abnor-mality of gait), in M0240. In this case, you wouldn't list a code from the V57.x series at all, says Twombly. But you would also list V43.65 (Organ or tissue replaced by other means; joint; knee) to further describe the patient's joint replacement.

Report a V57.x code as a first-listed (or primary) diagnosis only if the patient is admitted principally for therapy intervention due to a resolving disease or injury, or a chronic, long-term condition and is being seen mainly for rehabilitation care, says Jun Mapili, PT, MAEd, rehab therapies supervisor for Global Home Care in Troy, MI.

Don't forget: As of December 2005, codes from the V57.x series can be reported only in M0230. These codes can no longer be listed as secondary diagnoses in M0240.

Mapili's camp advocates using V57.x codes in therapy-only situations. See "Add Up Your Therapy Claims With These Coding Equations" on page 27 for Global Home Care's V57.x coding formulas.

Caution: Don't list a V57.x code as a therapy medical diagnosis, Mapili says. These codes should be coupled with codes for medical conditions (related to the need for therapy), and/or a treatment diagnosis. Don't report a V57.x code alone, he says.

The bottom line: Neither camp can say they are absolutely correct at this time -- they're both still waiting for further clarification.

1. No risk adjustment benefit. V codes don't provide important risk adjustment for your outcomes. If therapy is primary, consider reporting the condition requiring therapy rather than a V code.
2. Increased risk of claims being pulled for an edit. Regional Home Health Intermediary (RHHI) edits are set to check claims for the use of the V57.x codes. Using these codes is like throwing up a red flag for additional scrutiny.

Watch out: The RHHIs are going to equate the use of V57.x codes with the functional scores in the OASIS assessment, predicts Twombly. To prevent denials, agencies need to make sure that a patient's functional score indicates the need for therapy.

Crucial: Include in the documentation everything that supports the need for therapy in your patient's case, Mapili says. Remember that the decision to utilize physical therapy is based on whether the service is complex enough that it can be performed safely or effectively only by a skilled therapist or under the general supervision of a skilled therapist.