Home Health ICD-9/ICD-10 Alert

Don't get caught upcoding when therapy focuses on proximate cause.

When you're coding for therapy, V57.x (Care involving use of rehabilitation procedures) may be at the top of your list. But before you list one of these oft-used "reason for encounter codes," make sure you're not falling into one of these common pitfalls.

V57.x codes will not increase your agency's reimbursement, says Jun Mapili, PT, MAEd, with Global Home Care in Troy, Mich. The V57.x codes aren't case mix codes and you shouldn't report one when therapy is an incidental service. The V57.x codes report "admissions for therapy" or "encounters for rehabilitation," Mapili says.

Use these codes when the patient is admitted for the sole purpose of undergoing rehabilitative therapy, Mapili says. If the therapy is an incidental treatment and the plan of treatment is not solely directed toward rehabilitation, don't use V57.x.

The new ICD-9-CM Official Guidelines for Coding and Reporting confirm this, stating "These codes should not be reported if they do not meet the definition of principal or first-listed diagnosis." If the patient is not admitted for therapy only, then you shouldn't use V57.x at all.

Coding scenario: Your patient was admitted to home health care due to acute exacerbation of multiple sclerosis. Skilled nursing is prescribed for observation and assessment and teaching of new medications. Physical therapy will provide progressive muscle strengthening due to progressive muscle weakness, transfer training, and activities of daily living (ADL) modification and training. A home health aide will assist the patient with ADL and personal care.

In the scenario, you would not report V57.1 (Other physical therapy) in M0230, Mapili says. The reason for admission in this case is more than just muscle weakness and the focus of care isn't simply rehabilitation -- instead, the care is directed at an acute exacerbation of multiple sclerosis.

This is an example of therapy as an incidental service, Mapili says. Remember that nursing is also providing observation and assessment and teaching of new medications. Instead, you would code for the patient's multiple sclerosis.

Bonus: Multiple sclerosis (340) is a case mix diagnosis and can bring extra payment while V57.x doesn't.

Take note: Complications of medical or surgical care, such as infections or wound dehiscence ,trump any type of V code, including the therapy codes, Mapili says. In these cases, you should list a condition-specific code instead. For example, for a patient with an infected surgical wound post-joint replacement, you would list 998.59 (Other postoperative infection) rather than a V code.

When rehabilitation therapy for a proximate diagnosis is the primary reason for admission, list the proximate diagnosis rather than the underlying cause after V57.x, Mapili says. Do not list the underlying cause first if the therapist is addressing the proximate diagnosis.

Coding scenario: Your patient was referred to home health due to new onset of movement incoordination due to Parkinson's disease. You'll be providing physical therapy for movement coordination training, balance training, bed mobility, and transfer training with a visit frequency of two times per week for seven weeks. Both dressing upper body and lower body in the OASIS (M0650 and M0660) were scored 2. The patient has no home health admission in past 60 days (early episode). For this patient,

Mapili suggests coding as follows:

• M0230a: V57.1

• M0240b: 781.3 (Lack of coordination)

• M0240c: 332.0 (Parkinson's disease; paralysis agitans).

Your principal diagnosis is V57.1 because you're not caring for an acute condition and the patient was admitted for rehabilitation therapy, Mapili says. Before the underlying condition, list 781.3, the proximate diagnosis. This reflects need for the physical therapist's skill and validates the V57.x code.

The V57.x codes can't stand alone, Mapili says. You need to list another diagnosis to support the medical necessity, because these codes don't provide diagnosis details. In the example scenario, you wouldn't list 781.3 in M0246 because it's not a casemix diagnosis.

Parkinson's disease is the underlying cause of movement incoordination in this case, so you would list that diagnosis after 781.3. Parkinson's disease is a case mix diagnosis in the Neuro 2 category, Mapili says. And it doesn't have to be in the primary spot to earn points.

Coding tips: There are other codes that may be more specific than the V57.1 physical therapy code, depending on the care the patient is receiving, says coding and billing specialist Vonnie Blevins, HCS-D, with Houston-based Excellence Healthcare.

If the therapist is providing gait training with an artificial limb, then V57.81 (Orthotic training) is more specific.